'It is not the fading candle that one expects': general practitioner's perspectives on life-preserving versus 'letting go' decision-making in end-of-life home care

Background: Many general practitioners (GPs) are willing to provide end-of-life (EoL) home care for their patients. International research on GPs' approach to care in patients' final weeks of life showed a combination of palliative measures with life-preserving actions. Aim: To explore the GP's perspective on life-preserving versus letting go decision-making in EoL home care. Design: Qualitative analysis of semi-structured interviews with 52 Belgian GPs involved in EoL home care. Results: Nearly all GPs adopted a palliative approach and an accepting attitude towards death. The erratic course of terminal illness can challenge this approach. Disruptive medical events threaten the prospect of a peaceful end-phase and death at home and force the GP either to maintain the patient's (quality of) life for the time being or to recognize the event as a step to life closure and letting the patient go. Making the right decision was very difficult. Influencing factors included: the nature and time of the crisis, a patient's clinical condition at the event itself, a GP's level of determination in deciding and negotiating letting go and the patient's/family's wishes and preparedness regarding this death. Hospitalization was often a way out. Conclusions: GPs regard alternation between palliation and life-preservation as part of palliative care. They feel uncertain about their mandate in deciding and negotiating the final step to life closure. A shortage of knowledge of (acute) palliative medicine as one cause of difficulties in letting-go decisions may be underestimated. Sharing all these professional responsibilities with the specialist palliative home care teams would lighten a GP's burden considerably