| dc.description.abstract | Background
In palliative care, the focus is on symptom relief and good quality of life for patients with lifethreatening illnesses and their relatives. The proportion of people needing palliative care increases with an ageing population. The Norwegian healthcare service aims to provide care in the home rather than in hospitals and nursing homes, which is consistent with where most patients want to be cared for and die. Yet, most people die in nursing homes or hospitals. Collaboration around seriously ill and dying patients requires professional expertise and good communication between healthcare personnel.
The regular general practitioner (GP) is considered an essential participant in palliative care for home-residing patients. The National Guideline for Palliative Care in Norway underscores the crucial role of the GP. National guidelines for healthcare services are essential tools for translating updated medical knowledge into good-quality and equal health services for patients. Collaboration in palliative care for home-residing patients involves the GP; the municipal nursing service, which includes the oncology nurse (ON); and the hospital-based palliative care team (PCT), representing the secondary care level. To achieve optimal care, the health professionals must cooperate closely. GPs are perceived not to participate in palliative care as intended to ensure optimal trajectories for home-residing palliative patients.
Aims
This project aimed to gain insights into GPs’ experiences with palliative care and develop new knowledge about the GPs’ role in palliative care and the barriers to their participation. The project also aimed to investigate the extent to which GPs knew of and adhered to the national guideline. This means we compared the guideline as a “map” with the GPs’ reality, representing the “terrain”.
Materials and methods
We approached the research questions with two different methods. The first study was a questionnaire survey among GPs in Møre og Romsdal, a county in mid-Norway. In this study, we wanted to obtain an overview and general knowledge about GPs’ experiences in palliative care. This included their experiences from the final stage of life, home death, and the collaboration between primary and specialist healthcare services. The study also examined the extent to which the GPs were aware of essential guideline recommendations. The results were described using descriptive statistics in Paper I.
The second study was a focus group study. We conducted four group interviews with a total of 25 GPs. We based the interview guide for this study on the survey results from the first study and the guideline. We first asked the GPs about their experiences with palliative care and their perceived role in this work. We then discussed the GPs’ experiences with and views on the guideline for palliative care. The study aimed to gain a deeper insight into the GPs’ experiences. We used interpretive phenomenological analysis (IPA) in Paper II and reflexive thematic analysis (rTA) in Paper III.
Results
In the first study, we found that GPs had few palliative patients at any given time and that home deaths were rare. This made it challenging to maintain specialised knowledge and skills. The working methods recommended in the guideline were little used, and the guideline did not seem well implemented among the GPs. However, over half of the GPs regarded themselves as central and felt confident about participating in palliative care. GPs who worked at some distance from the hospital felt more secure and central than those who worked close to a hospital and were more available outside working hours (Paper I).
In the focus groups, we uncovered several strengths the GPs perceived themselves to have in palliative care provision. They emphasised continuity in the doctor–patient relationship, that they were used to coordinating patient care, and that they had unique knowledge of the patients and their families. The GPs believed that their competencies as generalists included knowledge that made it possible to alleviate the patients in many cases. They were positive about participating in palliative care. Nevertheless, they took different positions towards the GP’s role; while some were very involved in this work, others were less involved or uninvolved (Paper II).
In the further analysis of the interviews, we looked at barriers to the GPs’ participation in palliative care and implementation of the guideline. Many GPs lost contact with seriously ill patients when referred to the hospital, creating a threshold for getting back on track. Insufficient information from the hospital could make it difficult to know how and whether they should follow up with the patient. The GPs needed information about the patient’s prognosis. We found that different cultures for the collaboration between the GP, ON, and PCT were established in different places. The GPs in some areas thought that the municipal ON should interact mainly with the palliative care team at the hospital. Consequently, there was no call for the GP to get involved.
When the GPs discussed the guideline content, most felt it was too extensive for general practice. The competence requirements appeared unrealistic to an ordinary GP. Several felt that the working methods recommended in the guidelines did not fit into general practice and suspected that GPs had not participated in its preparation.
Conclusions
This thesis highlights that GPs can add unique qualities to the care of seriously ill and dying patients and that their skills complement those of other professionals in the field. Patients benefit when GPs participate in this interdisciplinary work. However, the guidelines’ requirements for the competence of GPs seem ambitious, and the division of labour is unclear. At present, we have insufficient knowledge about which level of competence the GPs need in addition to their broad competence as generalists to improve outcomes for their palliative patients. GPs are usually gatekeepers to specialised health services, and if they are bypassed, resources in specialised palliative care could be overstretched. This thesis also highlights some essential aspects of guideline creation for general practice. The consequences of guideline requirements need to be assessed at all levels of the health service to which it applies. GPs must follow many guidelines; therefore, considering a guideline’s impact on GPs’ workload is vital. Anticipating such consequences requires knowledge from the field of practice, and GPs should be strongly represented in the committees that draw up guidelines they are required to adhere to. | en_US |
