GPs and end of life decisions : views and experiences

The views and experiences of GPs with respect to end of life (EoL) care are seldom addressed. The aim of this article is to better understand this aspect of care. A cross-sectional survey of all doctors in the country was designed and set up. The overall response was 396 (39.7%), 160 of which were GPs. 28.7% of GPs received no formal training in palliative medicine. 89.8% of respondents declared that their religion was important in EoL care. 45.3% agreed with the right of a patient to decide whether or not to hasten the EoL. 70.5% agreed that physicians should aim to preserve life. 15% of GPs withdrew or withheld treatment in the care of these patients. 41.1% had intensified analgesia at EoL. 7.5% had sedated patients at EoL. Lastly, 89.1% GPs would never consider euthanasia. Significant correlation (p< 0.05) was observed between considering euthanasia, using sedation, importance of religion and patients’ rights in EoL. A thematic analysis of comments highlighted the importance of the topic and feeling uncomfortable in EoL care. In conclusion there needs to be more training in palliative care. GPs believe in preserving life, would not consider euthanasia but do not shun intensification of analgesia at the end of life. There might be some misunderstanding with respect to the role of sedation at the EoL. GPs need legal and moral guidance in EoL care, in the absence of which, their religion is used as a guide.peer-reviewe

Practical aspects of palliative care

Palliative Care is a relatively young medical specialty. In fact, it was only in 1987 that it was recognised as such in UK. The aim of this contribution is to highlight some important but practical points in the practice of palliative care, especially with respect to the ethical aspects of palliative care.peer-reviewe

A case of hypertension

You are consulted by MB, a 58 year old lady. She is single and works as a manager with a leading advertising agency, keeping up with a lot of deadlines. During the visit, which was mainly related to some minor elbow complaint, you discover a raised blood pressure of 170/95 mmHg. Subsequent visits confirm the raised blood pressure. She is known to suffer from dyslipidaemia, with a LDL-cholesterol of 4.5mmol/L and a total cholesterol of 6.3mmol/L. MB does not smoke. How would you manage this case?peer-reviewe

General practice

The remarkable rate of development of medical knowledge and pharmacology affects all medical specialties and in particular general practice, since the latter embraces various aspects of different medical fields. Certain areas of medical practice, such as Hormone Replacement Therapy (HRT), hypercholesterolaemia and drugs affecting the Renin Angiotensin System (RAS) feature in a vast amount of literature which is constantly being updated. The increasing awareness of the previously unknown effects of HRT on one side, and the widespread prevalence of cardiovascular disease in the case of hypercholesterolaemia and drugs affecting the RAS have contributed to this large amount of studies. On the other hand, certain areas of practice such as atopic eczema and anti-thrombotic therapy have been rather quiescent as far as developments are concerned, but revolutionary treatments have recently been introduced in both areas, namely the calcineurin antagonists and ximelagratan. The latter is a very promising drug which can replace warfarin, while the former are the first steroid-sparing medications which effectively control atopic eczema. Keeping abreast with recent developments is a further hurdle which the modern general practioner has to contend with in order to offer valid treatment options, and to be able to answer questions by increasingly well-informed patients.peer-reviewe

Adult learning theories and medical education : a review

Adult learning theories describe ways in which adults assimilate knowledge, skills and attitudes. One popular theory is andragogy. This is analysed in detail in this review. The importance of extrinsic motivation and reflective practice in adult learning is highlighted, particularly since andragogy fails to address adequately these issues. Transformative Learning is put forward as an alternative concept. Using the three recognised domains of knowledge, skills and attitudes, ways of applying these theoretical concepts in medical education are subsequently discussed.peer-reviewe

Promoting family medicine

The year 2002 saw the publication of a landmark white paper in the United Kingdom entitled "Shifting the balance." It proposed redistribution of funds with the lion's share of the NHS budget going towards Primary Care services. Soon after, the white paper was approved, and at present 75% of the NHS budget is directed towards primary care.1 This underpins the importance and priority which the government in the United Kingdom gives to primary care in order to have an effective health system.peer-reviewe

Maltese doctors : views and experiences on end of life decisions and care

Background: End of life (EoL) decisions are important and challenging for doctors. Aim: To better understand, describe and quantify this aspect of care. Methodology: A national cross-sectional validated survey was mailed to all doctors of the country. Results: The response rate was 39.3%. The respondents had been practicing for 19.72 years (95% CI: 18.3 – 21.0). 86% of respondents declared that their religion was important in EoL care. 42.9% (25.6% disagreed, 31.5% neutral) agreed with the right of a patient to decide whether or not to hasten the end of life. 48.6% agreed (34% disagreed, 17.4% neutral) that high quality palliative care nearly removes all requests for euthanasia. 60.4% agreed (23.9% disagreed, 15.7% neutral) that physicians should aim to preserve life. Each doctor cared for an average of 10.5 EoL (95%CI: 8.45-12.64) patients in the prior 12 months. 32.1% of doctors withdrew or withheld treatment in the care of these patients. Of the remaining 67.9%, 36.6% agreed with such practices. 50.3% had intensified analgesia at EoL with the possibility of hastening death. Only 6% had sedated patients at EoL. Lastly, 11.9% received request for euthanasia whilst 90.2% of doctors would never consider euthanasia. Significant correlations were observed between considering euthanasia, importance of religion, withdrawing/withholding treatment, doctors’ specialty, preservation of life and request for euthanasia. A thematic analysis of comments highlighted the importance of the topic, feeling uncomfortable in EoL care, the religious aspect of care, lack of legal framework and the challenge of symptom control. Conclusions: The overall majority of doctors is against euthanasia. There is a strong sense of guidance by their religious beliefs when it comes to EoL care. Doctors believe in preserving life as a guiding principle at the end of life, but do not shun intensification of analgesia at the end of life. Different specialties have slightly different views on EoL. Doctors need guidance – legal and moral - on this subject, in the absence of which, their religion and philosophy of life is used to guide them in this rather difficult area of practice.peer-reviewe

A study on the attitudes of foundation doctors in Malta towards general practice and their experience while working in the specialty

Introduction: A substantial number of Foundation year (FY) doctors have a three month rotation in family medicine at the health centres in Malta. The aim of the study was to understand the factors that influence FY doctors’ attitudes towards general practice (GP) and the potential reasons why these doctors would choose a career in GP. Method: This consisted of a cross-sectional questionnaire study carried out with FY doctors in Malta. The online server Google Forms was used to collect data and manage the questionnaires. Data was extracted to Excel 2010 with which it was analysed. Results: Over the one-year study period 61 FY doctors had a GP rotation. The questionnaire response rate was 54%. For 72.7% of respondents, choosing a rotation in GP had been a priority; of these, 88% would consider a career in GP but it was the preferred career choice for only 50%. Sixty-nine point six per cent of doctors gave a very positive rating (more than 7 out of 10) of their experience at health centres, and 78.8% experienced a positive change in attitude towards the specialty of family medicine after this rotation. The rotation was rated as having the greatest influence on career choice. Quality of life was the most popular factor attracting doctors to GP. Lack of respect towards general practitioners and the challenge of managing clinical uncertainty with patients in family medicine were the two main factors which discouraged doctors from such a career. Conclusion: General practice is a popular specialty in Malta and the Foundation rotation in GP was found to be one of the main factors influencing career choice. In view of this, it should be ensured that during the rotation doctors get a complete experience of general practice, which is a true reflection of what the specialty entails.peer-reviewe

An evaluation of the conservative management of fractures with plaster in a Maltese primary health centre

Introduction: Fracture management still remains a grey area in primary care internationally. In Malta, conservative fracture management operates as the Plaster Slab Service, a service which has never been evaluated. The purpose of this study is to assess this service in Mosta Health Centre (MHC) – the only health centre with a 24/7 X-ray service. The objective is to find common trends and to increase primary care awareness on conservative fracture management. Method: In this cross-sectional study, all patients who had a plaster cast done at MHC between August and December 2017 were included. Retrospective data was collected including demographic data (age, gender, locality), time of application, type of injury and plaster, problems related to the slab and wound healing as well as whether a repeat X-ray was taken. Results: Most plaster casts were required for the younger age group with another peak in the 60s-70s age group. Younger patients showed a significantly increased risk of sustaining a scaphoid or radial fracture. There was a significant link between patients’ locality and time of presentation. Only 44.6% of scaphoid fractures had a repeat X-ray done as follow up. Complications to fracture healing amounted to 1% whilst 5% had problems with the cast. Conclusion: At primary care level, a wide range of fractures can be successfully managed with a very low rate of complications. Possible areas for improvement include guideline adherence in the follow-up of fractures.peer-reviewe

An evaluation of palliative care education in the specialist training programme in family medicine

Aim: The study aimed to evaluate the teaching in palliative care (PC) provided during the Specialist Training Programme in Family Medicine (STPFM) in Malta. Methodology: A questionnaire was used, based on two other validated questionnaires used in a similar population. Fifteen topics commonly encountered in PC were analysed. Results: Twenty-two (74.4%) trainees returned the questionnaire. All trainees received exposure to palliative care patients, but only 5 (22.7%) felt involved in their care and only 6 (27.3%) ever used a syringe driver. Most PC teaching in the STPFM was formal in nature. Trainees felt that palliative care subjects were covered well in the STPFM, but non-medical areas received lower scores. Trainees’ confidence closely mirrored the scores for subject coverage. The Half-Day Release Programmes were the most useful palliative care teaching resource. A correct answer for the question on pain management was obtained by 63.3% of trainees and 23.7% got a correct answer for the question on the use of a syringe driver. Concerns on managing dying patients in the community were raised by 40.9% of trainees. Trainees judged overall positively their STPFM. Conclusion: GP trainees need to be trained in PC in a manner that adequately addresses their future caseload. Changes need to be made in the PC teaching within the STPFM to address areas such as ethical issues in end-of-life; using a syringe driver; selfcare and managing patients in the community.peer-reviewe