Systematic review of the effectiveness, barriers and facilitators to general practitioner engagement with specialist secondary services in integrated palliative care

The general practitioner (GP) has a critical role in an integrated model of palliative care as they often know the patient and carer well, are experts in generalist care and have knowledge of health and social services in the community. Specialist palliative services have insufficient capacity to meet demand and those with non-cancer terminal conditions and those from rural and remote areas are underserved. Research has focused on improving access to palliative care by engaging the GP with specialist secondary services in integrated palliative care. OBJECTIVES: (1) Evaluate the effectiveness of interventions designed to engage GPs and specialist secondary services in integrated palliative care; and (2) identify the personal, system and structural barriers and facilitators to integrated palliative care. METHOD: MEDLINE, EMBASE and CINAHL were searched. Any study of a service that engaged the GP with specialist secondary services in the provision of palliative care was included. GP engagement was defined as any organised cooperation between the GP and specialist secondary services in the care of the patient including shared consultations, case conferences that involved at least both the GP and the specialist clinician and/or other secondary services, and/or any formal shared care arrangements between the GP and specialist services. The specialist secondary service is either a specialist palliative service or a service providing specialist care to a palliative population. A narrative framework was used to describe the findings. RESULTS: 17 studies were included. There is some evidence that integrated palliative care can reduce hospitalisations and maintain functional status. There are substantial barriers to providing integrated care. Principles and facilitators of the provision of integrated palliative care are discussed. CONCLUSIONS: This is an emerging field and further research is required assessing the effectiveness of different models of integrated palliative care

The needs of cancer patients and their families from rural and remote areas of Queensland

This study examines the impact of travelling for treatment on cancer patients and their families. Twenty-eight consecutive cancer patients, who were receiving radiation therapy treatment and 19 family carers, completed a structured needs assessment questionnaire and an in-depth interview. Both patients and carers reported moderate to high levels of unmet psychological need. Carers were found to have higher levels of anxiety than patients, although both groups had higher anxiety levels than the general population. Taking more responsibility for household tasks and organising new living arrangements for the family were the most frequently identified demands of a dual burden of caring. Nearly 40% of carers reported some disruption to their schedule and half reported experiencing financial difficulties. The qualitative interviews highlight the disruption that parents and children experience under the present system, particularly in relation to the demands of family life and the need to maintain some level of continuity and security for children

General practitioners’ engagement in end-of-life care: a semi-structured interview study

Early identification of approaching end-of-life and care planning improve outcomes at the end of life. Nevertheless, the majority of people who die are not identified in time to enable appropriate care planning. We aimed to describe the challenges general practitioners (GPs) found in providing end-of-life care; what prompted GPs to identify and discuss approaching end of life with their patient and how their practice changed.We conducted a qualitative study of 15 Australian GPs using semi-structured interviews, examining end-of-life care of one of their randomly selected, deceased patients. Interviews were analysed using a general inductive approach.When a life-limiting prognosis was articulated, GPs integrated end-of-life care into their clinical care directly. Care often included a care plan developed in consultation with the patient. Even when death was not articulated, GPs were aware of approaching end of life and changed their focus to comfort of the patient. GPs generally had an informal care plan in mind, but this developed gradually and without discussing these plans with the patient. How GPs provided end-of-life care depended primarily on patient traits (eg, willingness to discuss physical decline) and the GP's characteristics (eg, experience, training and consulting style).GPs were aware of their patients' approaching end of life and care was adjusted accordingly. However, under certain circumstances this was not explicitly articulated and discussed. It is not clear if implicit but unarticulated end-of-life care is sufficient to meet patients' needs. Future studies should investigate this

A series of n-of-1 trials of stimulants in brain injured children

Background: There is controversy about whether central nervous system stimulant (CNS) medication is an effective method of treating acquired attention deficits in children with acquired brain injury (ABI). OBJECTIVE: The primary objective was to determine the effectiveness of stimulants on attention, concentration and executive function in children with ABI. METHODS: Randomised, double-blind, placebo-controlled, multi-centre n-of-1 trials of stimulants assessing effect on attention, concentration and executive function in 53 children and adolescents with ABI who were outpatients of three tertiary hospitals in Australia. Trials consisted of 3 two-week cycles, each cycle consisting of stimulant medication at doses titrated by physician (1 week) and placebo (1 week) in random order. The effect on parent and teacher Conners' 3 and Behaviour Rating Inventory of Executive Function (BRIEF) was analysed using hierarchical Bayesian methods. RESULTS: Overall, Teacher Conners' Hyperactivity/Impulsivity and Teacher BRIEF Global Executive scales showed important improvement (T-score mean change 2.6; 95 credible interval (CI): 0.4, 4.9; posterior probability of mean change >0:0.99; T-score mean change 3.1; 95 CI: -0.1, 6.4; posterior probability of mean change >0:0.97). There were no important improvements in parent/guardian-reported primary outcomes. There was heterogeneity in response identified through individual results of the N-of-1 trials. CONCLUSIONS: N-of-1 trials have a clear role in identifying those children/adolescents with ABI and secondary Attention Deficit Hyperactivity Disorder (ADHD) who have important improvements, or worsening on stimulants. The results can only be generalized to children/adolescents who have an apparent pre-trial clinical effect from stimulants

Testing pilocarpine drops for dry mouth in advanced cancer using n-of-1 trials: A feasibility study

Background: Dry mouth is a common and troublesome symptom in palliative care. Pilocarpine is a cholinergic agent that promotes salivation