ArticlePDF Available

PaTz groups for primary palliative care: Reinventing cooperation between general practitioners and district nurses in palliative care: An evaluation study combining data from focus groups and a questionnaire

Authors:

Abstract

PaTz (an acronym for 'PAlliatieve Thuis Zorg'; palliative care at home) is an intervention to improve palliative care provision and strengthen the generalist knowledge of palliative care. In PaTz general practitioners and district nurses meet on a regular basis to identify patients with palliative care needs and to discuss care for these patients. This study explores experiences with regard to collaboration between general practitioners and district nurses, and perceived benefits of and barriers for implementation of PaTz. This study is conducted within the primary care setting. Participants were 24 general practitioners who filled in a questionnaire, and seven general practitioners, five district nurses and two palliative care consultants who attended one of two focus groups. PaTz led to improved collaboration. Participants felt informational and emotional support from other PaTz participants. Also they felt that continuity of care was enhanced by PaTz. Practical recommendations for implementation were: meetings every 6 to 8 weeks, regular attendance from both general practitioners and district nurses, presence of a palliative care consultant, and a strong chairman. PaTz is successful in enhancing collaboration in primary palliative care and easy to implement. Participants felt it improved continuity of care and knowledge on palliative care. Further research is needed to investigate whether patient and carer outcomes improve.
A preview of the PDF is not available
... To manage terminal patients to increase the quality of dying, different models in general practice have been developed, that establish safe organizational pathways for the dying and their relatives. In the Netherlands, models have been developed, where groups of GPs and district nurses have regular interprofessional meetings with support from a palliative care consultant to discuss specific and present patient issues [14], and in several countries, both GPs and palliative care specialists provide palliative care [15][16][17]. Generally, there has been an increased focus on palliative care for patients with cancer diagnoses [18]. ...
... However, for patients with organ failure illnesses as seen in old age, palliative care has not been studied as widely. Furthermore, previous studies have suggested and tested methods to promote GPs' competencies in palliative care [14,19] and a lot of studies have been made on GPs' challenges and barriers in providing palliative care [20][21][22][23], but there is a lack of equivalent focus on factors enabling GPs in providing palliative care. The aim of this exploratory systematic review of qualitative literature was to identify roles, tasks and approaches of GPs enabling palliative care, by exploring the experiences of GPs, other healthcare professionals, patients, and their relatives. ...
... Various models to enhance palliative care provided by GPs have been evaluated [14,19,[40][41][42]. One of them described the development of the Patz group consisting of GPs, district nurses and a palliation specialist as the facilitator of the collaboration [14]. ...
Article
Full-text available
Background Many elderly people wish to die at home but end up dying at the hospital. If the patient wishes to die at home, palliative care provided by General Practitioners (GPs) may increase the chance of dying at home, however, there is a lack of knowledge on how GPs should provide palliative care. We aimed to identify roles, tasks and approaches of GPs enabling palliative care, by exploring the experiences of GPs, other healthcare professionals, patients, and relatives through a systematic review of the qualitative literature. Methods We searched PubMed, EMBASE, PsycINFO, Web of Science, and CINAHL in March 2022. Thematic analysis was used for synthesizing the results. Results Four thousand five hundred sixty three unique records were retrieved, and 12 studies were included for review. Of these, ten were interview or focus group studies and two were survey studies with additional open-ended questions. Only qualitative findings from the studies were used in synthesizing the results. Thematic analysis produced four main themes describing the roles, tasks and approaches of GPs enabling palliative care to increase the chance for patients to die at home. GPs can support patients in the final phases of life by applying a holistic, patient-centred, and proactive approach to palliative care and by having sufficient education and training. Furthermore, the palliative care consultation should include symptom management, handling psychosocial and spiritual needs, maintaining a fragile balance, and proper communication with the patient. Lastly, GPs must address several palliative care elements surrounding the consultation including initiating the palliative care, being available, being the team coordinator/collaborator, providing continuous care and having sufficient knowledge about the patient. Conclusions The roles, tasks and approaches of the GPs enabling palliative care include being aware of elements in the palliative care consultation and elements surrounding the consultation and by having sufficient education and training and a broad, proactive, and patient-centred approach.
... First, that lack of awareness of, communication with, and valuing of the other team are important in collaborations between inpatient hospital medicine specialists and community primary care providers at time of hospital discharge. [34][35][36][37] Second, that factors which enhance collaboration between specialist and generalist palliative care professionals include established interpersonal relationships, 11,12,38 frequent, proactive communication, 18,19,39 and respect for the other team's contributions. 38,39 This study was the first to construct an integrated theory, proposing relationships between conditions and the way in which teams function. ...
... [34][35][36][37] Second, that factors which enhance collaboration between specialist and generalist palliative care professionals include established interpersonal relationships, 11,12,38 frequent, proactive communication, 18,19,39 and respect for the other team's contributions. 38,39 This study was the first to construct an integrated theory, proposing relationships between conditions and the way in which teams function. It was also first to introduce the more abstract concept of team self-perception as a driver of how teams function in relation to the other team. ...
Article
Full-text available
Background Individuals with palliative care needs face increased risk of discontinuity of care as they navigate between healthcare settings, locations and practitioners which can result in poor outcomes. Little is known about interactions that occur between specialist and generalist palliative care teams as patients are transition from hospital to community-based care after hospitalisation. Aim To understand what happens between inpatient specialist palliative care teams and the generalist teams who provide post-discharge palliative care for shared patients. Design A constructivist grounded theory approach, using semi-structured interviews and constant comparative analysis, including coding, memo-writing and diagram construction. Settings/participants Interviews (n = 21) with specialist palliative care clinicians and clinicians in other specialties providing generalist palliative care. Specialists had training in palliative care and worked in specialty palliative care practices; other clinicians worked in primary care or oncology and did not have specialised palliative care training. Results A grounded theory of interdependence between specialist and generalist palliative care teams across healthcare settings was constructed. Two states of inter-team functioning were found which related to how teams perceived themselves: separate teams or one cross-boundary team. Three conditions influenced these two states of inter-team functioning: knowing the other team; communicating intentionally; and acknowledging and valuing the role of the other team. Conclusions Teams need to explicitly consider and agree their mode of functioning, and enact changes to enhance knowledge of the team, intentional communication and valuing other teams’ contributions. Future research is needed to test or expand this theory across a range of cultures and contexts.
... Currently, initiatives for early identification of patients in their last phase of life have tended to overrepresent people with terminal cancer. 44,45 The recognition of patients with limited life expectancy and medications could be systematically incorporated into primary care, following the Scottish Key Information Summary (KIS) example, where complex patients are selected to capture clinical (baseline) status and anticipatory care plans in a shared document between various health care practitioners, to better ensure 'one voice' in patient and caregiver communication. 46,47 In addition, in this study, nurses were interested to play a role in deprescribing. ...
Article
Full-text available
Background For people with limited lifetime expectancy, the benefit of many medications may be outweighed by their potential harms. Despite the relevance of reducing unnecessary medication use, deprescribing is poorly enacted in primary care practice. Aim This study aims to describe factors, as identified by primary care professionals and patients, that influence deprescribing in the last phase of life. Design Semi-structured interviews were conducted and analysed using a thematic approach. Setting/participants This study was performed in primary care settings, including general practices, hospices and community care teams in The Netherlands. Purposefully identified primary care professionals (general practitioners, pharmacists, nurses) and patients with limited lifetime expectancy due to advanced chronic illness or cancer and their caretakers were interviewed. Results Three themes emerged detailing factors influencing deprescribing in the last phase of life in primary care: (1) non-maleficence, the wish to avoid additional psychological or physical distress; (2) reactive care, the lack of priority and awareness of eligible patients; and (3) discontinuity of care within primary care and between primary care and specialty care. Conclusions Deprescribing is an incremental process, complicated by the unpredictability of life expectancy and attitudes of patients and health care professionals that associate continued medication use with clinical stability. Opportunities to facilitate the deprescribing process and its acceptance include the routinely systematic identification of patients with limited life expectancy and potentially inappropriate medications, and normalisation of deprescribing as component of regular primary care, occurring for all patients and continuing into end-of-life care.
... 8 A Dutch study of collaboration between general practitioners and district health nurses in home palliative care suggested that the collaboration was improved by meetings every 6-8 weeks and regular participation by the general practitioners, district health nurses, and a palliative care consultant. 9 However, the process and effects on the community of collaboration between general practitioners and public health nurses in primary care are not fully understood. ...
Article
Full-text available
Background Interprofessional collaboration in the community is becoming essential in primary care, particularly collaboration between public health nurses and general practitioners. However, the precise value of such collaboration has not been sufficiently studied. The purpose of this study was to conduct a qualitative analysis of collaboration between general practitioners and public health nurses in the community to explore the details of the phenomenon and its possible impact on the community. Methods Since 2015, The University of Toyama has been implementing the Collaborative Health Activities Project, in which general practitioners and public health nurses work together to promote community health. Focus group and individual interviews were conducted with participating staff, and the data were analyzed qualitatively. Results Fifteen themes were generated, in six categories. The categories were as follows: enhanced roles of public health nurses and physicians in the community, new perspectives on the community, public health nurses' sense of trust and empathy toward physicians, bonds of solidarity between public health nurses and physicians, proactive change in residents, and supporting “hangout places”. Conclusion The collaboration between general practitioners and public health nurses familiar with the same community fostered a sense of trust and empathy and created the bonds of solidarity between staff and residents. The results also suggest the collaboration may have a positive impact on the local community by inspiring residents to change proactively and supporting “hangouts” where residents and professionals can informally connect.
... Both GPs and PNs are recommended to work together as a team as they have their own professional competencies for applying strategies at the EOL (Rockwood et al., 2005;Van der Plas et al., 2014). Studies indicate that a multi-disciplinary team with highly trained nurses reduces the chances of hospitalization at the EOL (Brumley et al., 2003;Ahlner-Elmqvist et al., 2004). ...
... Most nurses perceive their main task to be disseminating information about palliative care to colleagues, whereas some home care nurses also mentioned raising awareness, e.g. by visiting general practitioners to promote palliative care, having a coaching role towards colleagues and promoting palliative care in general. Hospital nurses seemed to be more modest about their added value than home care nurses, which may be the result of more hierarchical relationships in hospital [31] and a greater focus on cure than in home care [20,32]. ...
Article
Full-text available
Background One of the strategies to promote the quality of palliative care in non-specialised settings is the appointment of palliative care nurse champions. It is unclear what the most effective model to implement the concept of nurse champions is and little is known about palliative care nurse champions’ own views on their role and responsibilities. This paper aims to describe views of palliative care nurse champions in hospitals and home care on their role, responsibilities and added value. Methods In 2018, a qualitative interview study was conducted with 16 palliative care nurse champions in two hospitals and four home care organisations in the southwest of the Netherlands. The framework approach was used to analyse the data. Results Most palliative care nurse champions described their role by explaining concrete tasks or activities. Most nurse champions perceive their main task as disseminating information about palliative care to colleagues. A few nurses mentioned activities aimed at raising awareness of palliative care among colleagues. Most nurses were to a limited extent involved in collaboration with the palliative care expert team. Hospital nurse champions suggested that more support from the palliative care expert team would be helpful. Most nurse champions feel little responsibility for organisational tasks and inter-organisational collaboration. Especially hospital nurses found it difficult to describe their role. Conclusion The role of palliative care nurse champions in hospital and home care varies a lot and nurses have diverging views on palliative care in these settings. Comprehensively fulfilling the role of palliative care nurse champion is a challenge. Careful selection, training, support and task descriptions for nurse champions are needed to make the concept of nurse champions work in palliative care.
Article
Full-text available
Aim: To explore (1) experiences of primary care physicians (PCPs) and oncological medical specialists about providing care to patients living longer with incurable cancer, and (2) their preferences concerning different care approaches (palliative support, psychological/survivorship care support). Background: At present, oncological medical specialists as well as PCPs are exploring how to improve and better tailor care to patients living longer with incurable cancer. Our previous study at the in-patient oncology unit showed that patients living longer with incurable cancer experience problems in how to deal with a prognosis that is insecure and fluctuating. To date, it could be argued that treating these patients can be done with a 'palliative care' or a 'survivorship/psychosocial care' approach. It is unknown what happens in actual medical practice. Methods: We performed multidisciplinary group meetings: 6 focus groups (3 homogenous groups with PCPs (n = 15) and 3 multidisciplinary groups (n = 17 PCPs and n = 6 medical specialists) across different parts of the Netherlands. Qualitative data were analysed with thematic analysis. Findings and conclusions: In the near future, PCPs will have an increasing number of patients living longer with incurable cancer. However, in a single PCP practice, the experience with incurable cancer patients remains low, partly because patients often prefer to stay in contact with their medical specialist. PCPs as well as medical specialists show concerns in how they can address this disease phase with the right care approach, including the appropriate label (e.g. palliative, chronic, etc.). They all preferred to be in contact early in the disease process, to be able to discuss and take care for the patients' physical and psychological well-being. Medical specialists can have an important role by timely referring their patients to their PCPs. Moreover, the disease label 'chronic' can possibly assist patients to live their life in the best possible way.
Thesis
Full-text available
A partir de recherches effectuées et présentées s’est développée une réflexion sur les coûts du cancer en phase palliative et comment au-delà des mesures coercitives, il pourrait être possible, par différentes moyens cliniques, d’enseignements et de recherches, de limiter ces coûts.Méthode : L’existence en France de détresse financière a été identifiée ainsi que son impact sur la qualité de vie des patients atteints de cancer en phase avancé. Dans l’objectif d’améliorer la qualité de vie des patients, il est important de savoir d’où provient cette détresse financière et les différents coûts induits par le cancer. D’autres études ont été réalisées dont notamment une sur la fin de vie et sur les critères d’agressivité des soins qui peuvent être une source de dépenses ainsi que d’altération de la qualité de vie.Discussion : La collaboration, l’anticipation, la qualité de la formation et le développement de la recherche en soins palliatifs sont autant d’éléments pertinents pouvant impacter les coûts du cancer en phase palliative. Dans la littérature, ces différents coûts ne sont jamais étudiés en même temps. Tout ce travail conduit à la construction d’un protocole de recherche sur les coûts de la phase palliative chez les patients atteints de cancer.Conclusion : L’avenir est non seulement de mieux comprendre les dépenses imputables au cancer pour le patient et sa famille mais aussi d’avoir une réflexion plus globale en discutant de l’amélioration de la consommation des soins et des collaborations qui pourraient avoir un impact non négligeable tout en prodiguant des soins de meilleure qualité et en respectant l’individu ainsi que le collectif. La mort fera toujours partie de la vie quelles que soient les avancées médicales, elle est inéluctable mais la façon de mourir ne l’est pas. La clinique, la recherche et l’enseignement sont les 3 axes qui peuvent permettre son amélioration.
Article
Full-text available
Background Euthanasia has been regulated by law under strict conditions in the Netherlands since 2002. Since then the number of euthanasia cases has constantly increased, and increased exponentially for patients with dementia (PWD). The number of euthanasia requests by such patients is even higher. Recently, an interview study showed that physicians who are confronted with a PWD’s euthanasia request experience problems with communication, pressure from relatives, patients, and society, workload, interpretation of the law, and ethical considerations. Moreover, if honoured, the physician and patient may interpret the right moment for euthanasia differently. Aim To identify ways of supporting GPs confronted with a PWD’s euthanasia request. Design and setting Two expert nominal group meetings were organised with Dutch care physicians for older people, GPs, legal experts, a healthcare chaplain, a palliative care consultant, and a psychologist. Method A total of 15 experts participated in the meetings. Both meetings were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results Four themes emerged from the meetings: support provided by healthcare professionals, influencing public opinion, educational activities, and managing time and work pressure. The need for support was considered highest for GPs for all of these themes. Conclusion Consensus was reached with the help of experts on support needs for GPs confronted with euthanasia requests from PWD. A concise and clear explanation of the law is strongly desired. Changing public opinion seems the most challenging and a long-term aim. Communication training for finding the right balance between the physician’s professional responsibility and the patient’s autonomy should be made available, as a short-term aim.
Article
Full-text available
Workload, personal health behavior, and job satisfaction of the physicians are crucial aspects for the quality of care they provide. The aim of our study was to identify influencing factors on job satisfaction with regard to general practitioners' (GPs) characteristics such as age, gender, health behavior, body mass index (BMI), and workload. A cross-sectional survey with a sample of 1,027 German GPs was used. Job satisfaction was measured according to a modified version of the Warr-Cook-Wall job satisfaction scale. Further, we collected data about health behavior and BMI of GPs and demographic data. Group comparison was evaluated using ANOVA with Bonferroni correction for post-hoc tests. A linear regression analysis was performed in which each of the job satisfaction items were handled as a dependent variable. The response rate was 34.0%. GPs were rather satisfied with their job with the exception of "hours of work," "physical working condition," and "income." GPs working in cities had less working hours per week, less number of patients per day, longer consultation times, and a higher proportion of privately insured patients compared to GPs working in rural areas. Being female, a higher age, a good health behavior, a lower BMI, and a high proportion of privately insured patients were positively associated with job satisfaction. Our results suggest that job satisfaction depends on different aspects of working conditions and individual characteristics. Therefore, strategies to improve job satisfaction should target improving working conditions and activating physicians' health resources.
Article
Full-text available
Little is known about the existing barriers to cooperation among health professionals in basic level palliative care for terminally ill patients with cancer in primary health care. The aim of this study was to analyze health professionals' views on interprofessional cooperation in basic level palliative home care for terminally ill cancer patients. This study was a qualitative, descriptive study based on 7 semistructured group interviews conducted in the former Aarhus County, Denmark. Forty-three health professionals (23 family physicians, 5 chief physicians, and 15 home care nurses) were interviewed. Two main categories of problems were identified: (1) the organization of palliative home care (need for proactive planning from the start of the palliative trajectory, clear distribution of tasks, advancement of more efficient communication pathways, and improved accessibility to all health professionals) and (2) interaction between health professionals (increased knowledge of and respect for the competencies of other health occupations and individuals). The study indicates problems with respect to both the organization of the basic level palliative home care and the working culture among health professionals. The main issues: distribution of tasks, information exchange, availability, respect, and personal acquaintance are pivotal to improve the delivery of palliative home care, to training in palliative care and warrant future research.
Article
Full-text available
The Gold Standards Framework aims to optimize primary palliative care for patients nearing the end of their lives. This paper critically reviews the impact of the Gold Standards Framework since its introduction in 2001 and indicates direction for further research and development. Literature was accessed using specific databases and by contacting subject area specialists. The resultant literature was appraised using an established framework to evaluate healthcare interventions. Fifteen documents were reviewed. The quality of evidence is constrained by methodological limitations, but consistently demonstrates that the Gold Standards Framework improves general practice processes, co-working and the quality of palliative care. However, implementation of the Gold Standards Framework is variable and the direct impact on patients and carers is not known. We conclude that the Gold Standards Framework has considerable potential to improve end-of-life care, but further work is needed to support uptake and consistency of implementation. Additional evidence about patient and carer outcomes will add to existing insights.
Article
Full-text available
For the further development of palliative care, it is relevant to gain insight into trends in non-acute mortality. The aim of this article is twofold: (a) to provide insight into ten-year trends in the characteristics of patients who died from cancer or other chronic diseases in the Netherlands; (b) to show how national death statistics, derived from physicians' death certificates, can be used in this type of investigations. Secondary analysis of data from 1996 to 2006 on the "primary" or "underlying" cause of death from official death certificates filled out by physicians and additional data from 2003 to 2006 on the place of death from these certificates. Of the 135,000 people who died in the Netherlands in 2006, 77,000 (or 57%) died from a chronic disease. Cancer was the most frequent cause of death (40,000). Stroke accounted for 10,000 deaths, dementia for 8,000 deaths and COPD and heart failure each accounted for 6,000 deaths. Compared to 1996, the number of people who died from chronic diseases has risen by 6%.Of all non-acute deaths, almost three quarters were at least 70 years old when they died. Almost one third of the people died at home (31%), 28% in a hospital, 25% in a nursing home and 16% somewhere else. Further investments to facilitate dying at home are desirable. Death certificate data proved to be useful to describe and monitor trends in non-acute deaths. Advantages of the use of death certificate data concern the reliability of the data, the opportunities for selection on the basis of the ICD-10, and the availability and low cost price of the data.
Article
Full-text available
The Gold Standards Framework (GSF) has been widely adopted within UK general practices, yet there is little understanding of its impact on the provision of community palliative care services. This study presents data on the anticipation and adoption of the GSF within three Primary Care Trusts in North West England. Forty-seven interviews were conducted with generalist and specialist palliative and primary care professionals. Important aspects of the GSF identified were the patient register, communication and out-of-hours protocols. Positive benefits to professionals included improved communication between professionals and appropriate anticipatory prescribing. Negative aspects included increased nursing workload and the possibility of fewer or later visits for patients. Many respondents believed that the GSF needed local champions to be sustainable. Slow or incomplete adoption was reported. The GSF was recognised as important because it facilitated changes to previously difficult aspects of work between professionals, but few respondents reported direct benefits to patient care.
Article
This preliminary study seeks to establish a baseline of barriers to communication as identified by healthcare professionals (HCPs) working as part of interdisciplinary palliative care teams. A survey of barriers and difficulties in communicating with patients, families, and team members was distributed via e-mail to 138 palliative care health professionals working in different palliative care settings in Vancouver Island, Canada. Sixty-eight responses were received. Four major areas of difficulty were identified: (1) communication with patients and their families, (2) communication with team members, (3) lack of skills, and (4) related to the system in which the HCPs were working. Difficulties most frequently mentioned included information sharing about transitions to palliative care, inefficient team communication processes, role issues, frustration with lack of availability of GPs, need for specialized skills in communication, lack of time, and lack of coordination of information between agencies. Recommendations include interdisciplinary training, palliative care guidelines, organizational support for interdisciplinary delivery of care, specific communication protocols for teams, assigned team-meeting time, and training opportunities to help members function as a team.
Article
In the United Kingdom approaching 20% of people aged 85 years and over live in care homes and most will die there. Improving end-of-life care is a government health priority and homes may work with primary care staff and specialist palliative practitioners to provide comprehensive end-of-life care. Consequently effective collaboration between care home and health service practitioners is vital to ensure high quality end-of-life care. To evaluate the impact of a training programme to improve end-of-life care in nursing homes, on collaboration between nursing home staff and other health practitioners. Evaluation using survey methods and qualitative case studies. All 95 nursing homes in the first national 'Gold Standards Framework in Care Homes' programme in England were invited to participate in the evaluation. A survey of homes' characteristics, the approaches to end-of-life care, and liaison with other services, was completed pre and post programme implementation. Case studies were conducted in a sub-sample of 10 homes to provide important context and depth to the evaluation. Pre and post surveys were returned by 49 (52%) homes. Improved collaborations as a result of the programme were anticipated by 31% of managers. Challenges to collaboration included working with large numbers of general practitioners, out-of-hours services and access to specialist practitioners. Improved collaborations between home staff and health service practitioners were identified by 33% of managers as one of the main programme outcomes. Staff reported increased knowledge of end-of-life care, and enhanced confidence, which in turn resulted in improved communication and collaboration. Post-programme, staff felt more confident initiating contact and discussing residents' end-of-life care with general practitioners and those working in specialist palliative care services. The Gold Standards Framework in Care Homes programme can contribute towards end-of-life care by helping to improve the quality and quantity of communication and collaboration between nursing home staff and primary care and specialist practitioners. Further research is needed to determine why this was not consistent across all homes.