Bid to breathe new life into GPs' care of dying patients
By Danusia Osiowy
Dealing with the dying is a fact of life for GPs. But while caring for terminally ill patients has always been a difficult and draining part of general practice, it is also increasingly a controversial one.
A combination of GPs' out-of-hours opt-out and a post-Shipman nervousness over use of controlled drugs appears to have eroded confidence in palliative care services.
So is there evidence of a drop in standards? And how can GPs provide good-quality care for their dying patients without working inhuman hours or leaving themselves at medico-legal risk?
A survey released by the Department of Health earlier this month suggests many GPs are refusing to hold this particular hot potato. Only 16 per cent are providing palliative care out of hours, though most are dissatisfied with their local services.
A Pulse straw-poll of 13 palliative care specialists reveals concerns over the effects of the opt-out. Some 80 per cent say
it has damaged the standard
of palliative care, with 70 per cent reporting an increase in
referrals to specialist services as a result.
Dr Adrian Tookman, consultant oncologist at the Royal Free Hospital in London, says: 'Undoubtedly palliative care has suffered. Primary care has turned to specialist services to deliver out-of-hours care. Some are adequately resourced to provide this but others are not.'
Shipman's shadow hangs heavy, with another survey suggesting many GPs are reluctant to administer opiates to dying patients in case of accidental overdose. Some no longer stock the drugs at their practice.
Baroness Llora Finlay, director of the Institute of Medical Ethics and a consultant in palliative medicine, believes GPs are at risk of becoming disengaged from a pivotal part of their role.
'GPs who stop providing palliative care will fall out of practice and become less familiar, less confident in prescribing and less engaged with patients. Eventually the situation will de-skill the workforce,' she says.
But GP experts insist GPs will have to be compensated for the heavy and difficult workload.
Dr Julia Riley, a GP in Fulham and a consultant in palliative medicine at the Royal Marsden Hospital, says: 'On average a GP will have two to three dying patients so it's difficult to become experts. But specialists cannot offer the personal insight into a patient and their circumstances in the way a GP can.
'It's very emotionally intensive and rarely is a consultation ever simple. GPs should be adequately compensated for this.'
But she does not believe it is acceptable for GPs to opt out of palliative care because they are too afraid to carry the drugs. 'The drugs can be ordered for a patient and delivered to their home, avoiding the need for GPs to carry large amounts.'
Dr Stephanie Bown, director of education and communication at the Medical Defence Union, stresses GPs have a legal responsibility to provide drug treatment: 'Opiates are invaluable in terminal care.
'GPs should protect themselves by communicating with patients. Explain the prescription and its side-effects and preferably repeat it to relatives. Ensure records are kept up to date and a drugs register is maintained.'
Experts suggest better communication between specialists and GPs is also the key to plugging gaps out of hours.
Dr Ron Morgan, consultant in elderly medicine at the Princess Alexandra Hospital in Harlow, Essex, says a simple detail like better patient paperwork can make a real difference.
'Out-of-hours services have a low threshold for sending a patient to hospital. A patient card giving details of care and plans, together with an emergency drug box at home, can avoid 999 being dialled as an alternative.'
Meanwhile, the Government seems to have woken up to the need to expand access to specialist palliative care, with funding for new specialist care teams. And it appears there is no appetite to compel GPs to take on a greater role in palliative care out of hours.
Professor Ian Philp, the department's national director for older people, says: 'Most GPs are committed to the principle that if a person is dying and expresses a wish to die at home, they will do what they can to help.
'This doesn't necessarily mean 24-hour cover by the GP but it does mean rapid involvement within the realms of a palliative care team.'
Improving GP care of the dying
· Introduce a card held by the patient giving details of their care plan and medication
· Ensure any patient on a palliative care register is also logged with out-of-hours
co-op, so on-call GP has access
to patient's care plan and drug
· Access to palliative care drugs out of hours through pharmacy on call stocks or patient 'just in case' boxes
· Dedicated out-of-hours GP cover to prioritise palliative care calls
· Efforts to improve communication between primary and secondary care
Managing opiate use
· GPs have a legal responsibility to administer opiates, either themselves or through a trained staff member
· To avoid accidental overdose, follow national guidelines on recommended dosage, taking into account other medications and clinical conditions
· Communicate with patients and preferably relatives, explaining what a treatment does and what side-effects it
· Check the strength of preparations, document actions, comply with controlled drug regulations and maintain a
· If the situation remains complicated, seek advice from a consultant colleague in palliative care
· Ensure there is good communication among the team of people looking after the patient and that records are kept up to date