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Research ArticleProgram Description

Enhancing family physician capacity to deliver quality palliative home care

An end-of-life, shared-care model

Denise Marshall, Doris Howell, Kevin Brazil, Michelle Howard and Alan Taniguchi
Canadian Family Physician December 2008; 54 (12) 1703-1703.e7;
Denise Marshall
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Doris Howell
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Kevin Brazil
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Michelle Howard
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Alan Taniguchi
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Figures

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  • Figure 1
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    Figure 1

    Key components of the shared-care model for optimal palliative care

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    Figure 2

    Palliative care interprofessional team documentation

Tables

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    Table 1

    Service gaps in current practice

    TYPE OF GAPDESCRIPTION
    Access
    • Lack of early identification of patients owing to differing definitions of palliative population

    • Persistent lack of designated and dedicated coordinators or navigators to oversee organization, support case finding (patient rostering), and coordinate best practices across relevant care sectors

    • Lack of sufficient expert medical palliative care resources to assist family physicians with the provision of care (timely and consistent access, eg, after hours)

    Assessment
    • Lack of appropriate tools that allow family physicians to provide best practices care in home and community settings

    • Inconsistent or nonexistent application of outcome-based, EOL care domain assessment tools

    Care
    • Lack of skilled psychosocial, spiritual, and bereavement supports for EOL patients and families living in these communities

    • Lack of timely respite care, necessitating unwanted and undesirable hospital admissions and emergency room visits

    • Lack of timely communication and flow of information in a manner that allows family physicians to remain the key providers of continuous care

    • Lack of mechanisms that allow family physicians, in the context of their own office “teams,” to interact and collaborate directly with community palliative care team providers

    Education and decision support
    • Inability to model comprehensive palliative care, including best practice skills, knowledge, behaviour, and resources, for medical students and family medicine residents, owing to lack of structured contacts and resources

    • Lack of opportunities for practice-based continuing education utilizing academic detailing to develop best practices and collaborative skills

    • Lack of opportunities and resources (eg, salary replacement dollars) for mentorship, role modeling, and development of family physician practice “leads” who can be trained in turn

    • EOL—end of life.

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    Table 2

    Summary of topics covered

    TOPICDISCUSSION POINTS
    Pain
    • Pain management

    • Adjunct therapies

    • Pain scales

    • Use of steroids

    Other symptoms
    • Nausea and vomiting

    • Constipation, bowel troubles

    • Depression

    Emergent issues
    • Increased calcium and sodium levels

    • Cancer clinic treatment

    • Respiratory depression

    • Respiratory distress

    Management issues
    • Pharmacology of palliative care

    • Alternative therapies

    • Increased personal comfort level with managing care

    • Checklists or approaches to management

    • Home setting resources

    Prognostication
    • End-stage symptoms

    • Medications

    Communication
    • Delivering bad news

    • Difficult emotions, situations, and families (in anger or denial)

    • Communication regarding spiritual aspects of the end of life

    • Balance between needs of patients and families

    Team
    • Interaction with other health professionals

    • Role of team members and how to access

    • When to refer

    • View popup
    Table 3

    Themes from interviews with physician participants after the project

    FOCUS OF INTERVIEW QUESTIONSKEY IDEAS SHARED BY PARTICIPANTSKEY QUOTE SUPPORTING THEME
    Most valued component
    • Support of team

    • On-call access to physician specialist interdisciplinary team

    “[H]aving access to the palliative physician … because I never worked with a palliative care person before … that was a new experience for me … having that access was really expert, was really valuable”
    Effects on role or practice
    • Confidence in decision making

    • Sustained involvement

    “[M]y load is less. And that is very good, but I still feel I am involved in the sense that I don’t feel like I am abandoning my patient and I am still involved in terms of what’s going on, and in feeling part of it, and certainly looking after palliative patients is an important part of family medicine and very rewarding one …. it actually makes it go easier”
    Coordination of care
    • Ease of access

    • Comprehensiveness of support

    • Quality of communication

    “[I]t was easier to get more support into the home. I would say it … happened faster and was more comprehensive … in terms of getting more individuals involved with varying levels of expertise … and during duration of [the patients’] journey through palliative care … they were getting more hours of support. The dialogue with various team members was increased and … of a higher quality”
    Effects on quality of care
    • Anticipation of needs

    • Averted crises

    • Enabled home death

    • Reduced fears of suffering

    “I think it was fabulous … because, you know, when all the people have so much anxiety, can I handle this? What is the next crisis going to be? And I really get a sense from most of my families that everything that would come would be dealt with right ... the patients knew they were not going to be suffering; they knew they weren’t going to be in pain. Anything that happened, there was a solution for it”
    • View popup
    Table 4

    Themes from interviews with nurse participants after the project

    FOCUS OF INTERVIEW QUESTIONSKEY IDEAS SHARED BY PARTICIPANTSKEY QUOTE SUPPORTING THEME
    Most valued component
    • Access to palliative experts

    • Interdisciplinary team support

    • Access to on-call services

    “[M]ade a huge difference. Even just, you know, even though I didn’t have to access it very often, you know it’s there …. You know that, okay, this guy is really sick, if I get called there in middle of the night … I’ve got somebody else I can call instead of sitting there and thinking, okay well, I’ve done what I can but …”
    Effects on role or practice
    • Confidence in decision making

    • Better anticipation of needs

    “To pick somebody’s brain … when you’re in a situation and you’re thinking, okay … I don’t know what else to do here …. We’ve done everything we can do, and it was just nice to have that one person that you could just access and say ... okay [refers to Advanced Practice Nurse] what do I do now? …. She opened up different options, okay, maybe go this way instead of … you’re leaning too far that way, or she just gave you more insight”
    Coordination of care
    • Trust and respect between nurses and physicians

    • Quality of communication

    • Access to home services

    “[T]he network has been amazing ... even in the daytime. If the family doctor was on the project … I could phone in and … we were put right through to the doctors, and things were dealt with right away. And if the doctor wasn’t working there was always someone covering. And you were just put right through, and … I mean it was amazing. I’ve worked in [refers to town], and it’s like road block, STOP! Can’t go any further. It’s just horrible …. This was like [a] highway”
    Effects on quality of care
    • Enabled home death

    • Adjustment support

    “[W]e would never have gotten to the place before death that we were at … one situation was a single mom ... teenage kids … the psychosocial counselor … did a huge amount in getting things in order … helping them work out finances … preparing to get a minister in place … she wanted to stay at home [and] the teens couldn’t care for her … to be able to provide that care and have her stay home … she was able to accomplish everything she wanted before death … it involved shift nursing … visiting nursing … chaplain”
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Canadian Family Physician: 54 (12)
Canadian Family Physician
Vol. 54, Issue 12
1 Dec 2008
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Enhancing family physician capacity to deliver quality palliative home care
Denise Marshall, Doris Howell, Kevin Brazil, Michelle Howard, Alan Taniguchi
Canadian Family Physician Dec 2008, 54 (12) 1703-1703.e7;

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Enhancing family physician capacity to deliver quality palliative home care
Denise Marshall, Doris Howell, Kevin Brazil, Michelle Howard, Alan Taniguchi
Canadian Family Physician Dec 2008, 54 (12) 1703-1703.e7;
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