How do we cope with death?

We hope that general practitioners will consider counselling their dying patients more actively, including those in hospital where terminal care may be poorly handled psychologically. This entails a major change in training which we hope is taking place through vocational training schemes. We feel a change in attitude to be necessary by many general practitioners who often deal with death by evasion and untruth.     

How do we cope with death?

We hope that general practitioners will consider counselling their dying patients more actively, including those in hospital where terminal care may be poorly handled psychologically. This entails a major change in training which we hope is taking place through vocational training schemes. We feel a change in attitude to be necessary by many general practitioners who often deal with death by evasion and untruth.     

Death in practice

For a nationwide study of terminal care, Gallup Polls took a sample of 950 general practitioners. Fourteen questionnaires could not be delivered; 376 doctors (40 per cent of the register) returned forms; 313 doctors (33.4 per cent) provided information on 301 home deaths and 292 hospital deaths and responded also to statements about care of the dying.

The patients who died at home were well supported by the general practitioner and the family and neighbourhood network. Control of pain was perceived to be better at home. Patients dying at home were more likely to be aware of their impending death. General practitioners usually discussed the imminence of death with relatives, but few relatives and patients raised the question of terminating life. All the available major services were under-used. There was support for more hospices and for more spending on social services. Postgraduate medical education on care of the dying was considered to be inadequate.

     

Integrated care for patients with asthma: views of general practitioners.

BACKGROUND. In 1989, a shared or integrated care scheme was developed for hospital outpatients with asthma, using the computerized patient record system of Grampian Health Board, Scotland. Patients with asthma attending hospital clinics were entered into this scheme and were invited to attend their general practitioner instead of an outpatient clinic for review of their asthma. Three-monthly questionnaires covering clinical aspects of asthma were sent to these patients and their general practitioners; the latter then returned them to the specialist. Patients could be recalled to the hospital clinic if either the general practitioner or consultant felt this was necessary and all patients were reviewed after one year by the specialist. The success of integrated care for patients with asthma relies on the cooperation of general practitioners. AIM. The aim of this study was to investigate how this scheme worked in general practice, and general practitioners' perceptions of it, in order to identify factors that enhance or inhibit integrated care for patients with asthma in general practice. METHOD. A qualitative survey was carried out with a random, stratified sample of 38 of the 317 general practitioners in the region. Semi-structured interviews were designed to elicit general practitioners' accounts of their operation of integrated care and their attitudes towards the scheme. RESULTS. General practitioners perceived the scheme to have several advantages: the continuity and quality of care provided was improved; and the transmission of information between general practitioner and specialist was enhanced. Regular general practitioner reviews, instigated by standard letters generated by computer, were favoured as being clearly structured. Concerns were raised about the processing of paperwork, and the possibility that unnecessary reviews might be generated. CONCLUSION. Integrated care for asthma patients is an acceptable management option among general practitioners.     

Appropriate place of death for cancer patients: views of general practitioners and hospital doctors.

BACKGROUND. The majority of cancer patients in the United Kingdom die in a National Health Service hospital, a setting that is contrary to the wishes of those patients expressing a preference to die elsewhere, for example at home or in a hospice. AIM. A study was undertaken to determine clinicians' views of the appropriate place of death for cancer patients and to examine factors leading to patients being admitted to a hospital specialist services unit where they died. METHOD. A questionnaire was sent to all general practitioners and hospital doctors who had cared for cancer patients who had died between May 1991 and April 1992 in a single health district. The appropriateness of the place of death, whether the patient was terminally ill, reasons for hospital admission and effect on management had different resources been available were determined. RESULTS. A total of 1022 deaths attributable to cancer were recorded for patients registered with general practitioners in the study area. Questionnaires were returned by general practitioners for 951 of the deaths (93%); hospital doctors returned questionnaires for 216 out of 268 patients (81%) who had been admitted to hospital under the care of a consultant. For deaths which had occurred at home, in a community hospital, residential/nursing home or Marie Curie hospice, the place of death was considered appropriate by general practitioners in over 92% of cases. For deaths in the hospital specialist services unit the place of death was considered probably or definitely appropriate by general practitioners in 83% of the 212 cases, but not appropriate in 17% of cases (P < 0.001 compared with all other settings). Hospital doctors considered 27% of deaths in the unit inappropriate. Significantly fewer cases fulfilled the criteria for terminal illness (death expected and palliative treatment commenced) according to general practitioners among those dying in the specialist services unit compared with deaths elsewhere (P < 0.001). The most common main reasons for admission to the specialist services unit were for investigation, because of difficult symptom control (apart from pain) and for curative/active treatment. General practitioners reported that management of between a sixth and a quarter of patients admitted to the specialist services unit would have been affected by the availability of 24-hour home cover, community hospital beds and a city-based hospice. Among the group of patients fulfilling the study criteria for terminal illness, the effect of other services on patient management would have been considerably higher. CONCLUSION. A greater proportion of cases where patients died from cancer in settings other than a specialist services unit were considered appropriate by general practitioners compared with deaths in a specialist services unit. For a considerable minority of patients, death in a specialist services unit was not considered appropriate by the general practitioners or by the hospital doctors. Improvements in local hospice facilities, community hospitals and community support would mean that a substantial proportion of hospital admissions could be avoided and thus cancer patients could die in more appropriate settings.     

General practitioners' use of a mobile coronary care unit in a non-urban setting

The use that general practitioners made of the mobile coronary care unit operating from a district general hospital was monitored. Over half of the patients referred by their general practitioners to hospital with suspected acute myocardial infarction were removed by the mobile unit rather than by an ordinary ambulance. However, general practitioner selection of the more compromised patient for admission via the mobile unit indicated that the chance of this category of patient being admitted by the proven best means could be improved. Of the definite cases of infarcts removed to hospital by whatever means, the high proportion which were uncomplicated raises the question whether the general practitioner is attempting to select such patients for home rather than hospital care. The figures for the use of the mobile coronary care unit also indicate that education of the public remains an important task.     

Use of general practitioner beds in Leicestershire community hospitals.

BACKGROUND. The shift in care from secondary to primary services is likely to place greater demands on community hospitals. Before changes in the provision of community hospitals can occur, baseline data are needed, outlining their current use. AIM. A study was undertaken to obtain baseline data describing the use of general practitioner beds in Leicestershire community hospitals. METHOD. A three-month prospective, observational study was carried out between February and May 1992 using data from a questionnaire completed by nurses and general practitioners and from patient hospital records. Study patients comprised all patients admitted to general practitioner beds in all eight Leicestershire community hospitals. RESULTS. A 100% questionnaire response rate was obtained giving data on 685 hospital admissions. Around 70% of admissions were of patients aged 75 years and over. Of admissions, 35% were for acute care, 31% for respite care, 22% for rehabilitation, 7% for terminal/palliative care and 5% for other reasons. Fifteen per cent of patients had been transferred from a consultant bed. Of those not transferred, 91% were admitted by their usual general practitioner or practice partner and for 96% of these patients this was the general practitioner's first choice for care. There was significant variation in both the age mix and care category mix of patients between individual hospitals. Medical deterioration in an underlying condition and family pressure on the general practitioner or carers' inability to cope each contributed to around half of all admissions. Of all admissions, 38% lived alone, and 18% of carers were disabled. Incontinence was reported for 35% of patients, and 26% of all patients were of a high nursing dependency. There was low utilization of community services before admission and 33% received none. There was variation between individual hospitals in use of local and district general hospital investigations, specialist referral and types of therapy. Of 685 admissions 11% died during their stay. Of those discharged, 76% went to their own or a relative's home, 10% to a residential or nursing home and 9% were transferred to an acute bed. Nine percent of discharges were postponed and 10% were brought forward. On discharge to non-residential care, 26% of patients received no community services. CONCLUSION. Shifting resources from secondary to primary care is a priority for purchasers. Both the introduction of the National Health Service and community care act 1990, and acute units having increasing incentives for earlier discharge, are likely to place greater demands on community hospital beds. Not all general practitioners have the option of community hospital beds. Before access to general practitioner beds can be broadened, existing beds should be used appropriately and shown to be cost-effective. Purchasers therefore require criteria for the appropriateness of admissions to general practitioner beds, and the results of a general practitioner bed cost-benefit analysis.     

Effect of structured postgraduate medical education on the care of patients with diabetes.

BACKGROUND. Diabetes can be effectively treated and monitored in general practice. Postgraduate medical education at a local level is required to support this strategic shift of medical care from hospital to general practice. AIM. This study set out to determine whether a structured educational programme initiated by and led by general practitioners, but involving all health professionals, leads to improved care for diabetic patients. METHOD. The primary health care teams from 12 of the general practices in Tynedale, Northumberland who attend the local postgraduate centre and refer patients to the local general hospital were involved in the educational initiative which led to a locally agreed protocol for diabetic care. A comparison was made of data for all diabetic patients, registered with the general practitioners in 1991, in the years 1986 and 1991 (before and after the educational initiative) in order to determine the prevalence of diabetes, place of care and treatment received, and to collect clinical information. RESULTS. More patients received general practice care only or shared care in 1991 than in 1986. There was a reduction in the use of oral hypoglycaemic agents among non-insulin dependent diabetic patients and more patients were maintained on diet alone. A greater proportion of patients were referred to dietitians, ophthalmologists and chiropodists in 1991 than 1986, and there was increased recording of, examination of, and identification of, diabetic complications. Little change was found in the mean values for clinical parameters between the two years. CONCLUSION. Structured educational programmes involving all professionals are an effective way of producing protocols that are adhered to by all concerned, and lead to improved clinical care for diabetic patients.     

Patient counselling by primary care physicians: results of a nationwide survey.

The rate of patient counseling in primary care medicine is a pivotal element of inter-specialty differences in styles of care. Using national data on patient care provided in both ambulatory care settings and in the hospital, this study examines the use of counseling by general and family practitioners, pediatricians, internists, and obstetrician/gynecologists. The findings show substantial differences based on physician specialty, with highest rates of counseling for family practitioners and internists, and rates of patient education for these two specialties almost three times that for general practitioners. The data also show generally higher counseling rates for hospital care and for first encounters with patients, and a tendency for office-based pediatricians and solo general practitioners to use less patient counseling compared to their institution-based counterparts. Projections of annual visit rates for the United States show that general practice and internal medicine account for a disproportionate amount of patient counseling compared to other primary care specialties, based on patient volume.     

The psychiatric discharge summary: a tool for management and audit.

The aims of this study were to review the information needs of general practitioners in relation to the discharge of mentally ill patients; to design a discharge summary that would meet these needs and evaluate its use by junior hospital staff; and to assess the usefulness of this summary for audit. The information needs of general practitioners were identified from a review of the literature and from discussions with local general practitioners. A prototype discharge summary was designed and reviewed by a panel of general practitioners, regional advisors and course organizers from the south east Thames region. It was used for all patients discharged from the acute psychiatric ward in Hither Green Hospital over a 10 month period. One copy was given to the patient to take to the general practitioner, one was posted to the general practitioner and a final copy was kept in the patient's hospital records. The senior house officers found the summary easy to complete. It reduced uncertainty about what data to provide, and helped to focus on the most critical information needed by general practitioners for continuity of care. Using a pre-coded data collection sheet, analysis of the information on the summaries was easily done. It provided a rapid audit of caseload, diagnoses, therapy, methods of admission and discharge, length of stay, risk factors and roles of all involved in future management. This information can be of use to the psychiatric team, general practitioners and hospital managers and could be the first step towards the development of shared care.     

Use of acute medical and general-practitioner beds by the practitioners working in one new town

Patients admitted to hospital by a defined group of general practitioners under their own care differ in age, diagnostic category, perceived needs, use of services and outcome, from those admitted by the same general practitioners to consultant beds. However, problems of methodology have to be kept in mind when interpreting the results.These findings suggest that general practitioners see consultant and general-practitioner care as having different attributes but only broadly indicate the nature of these. This study has not attempted to answer the question of outcome: What are the needs of the patient which can be most satisfactorily met by different forms of care—consultant care, general-practitioner care in hospital, and general-practitioner care at home?The next stage must be the development of both a more valid measure of a wide range of needs, and controlled trials of care into the effects of different forms and place of care on patients with differing types of needs.     

Diabetes and its care--what do patients expect?

A sample of 77% of the non-insulin dependent diabetics aged 30-70 years from two urban practices offering no structured diabetic care were interviewed. The 55 patients (mean age 60 years) were asked about their experiences and expectations of diabetes and the health professionals involved in their care. Twenty-six patients attended the hospital diabetic clinic regularly but 13 patients received no review at all; 46 patients wanted their general practitioner to be involved in future care and only six wanted to continue with hospital review alone. Patients gave hospital doctors and general practitioners similar high ratings for knowledge of diabetes and its management but general practitioners and practice nurses were rated more highly for communication and accessibility. The aspect of care valued most was being given clear information about diabetic management. Twenty two patients thought that diabetes would have a significant impact on their future health and 35 rated regular diabetic review as extremely important in keeping themselves healthy. Most patients felt it likely that they would have a high blood glucose level most of the time and develop diabetic complications. Little difference was found between the views of clinic attenders and non-attenders, and there was no evidence that non-attenders had actively rejected review. These non-insulin dependent diabetics considered diabetes to be a serious disorder warranting regular care and expressed confidence in the primary care team's ability to provide such care.     

Home or hospital care for acute myocardial infarction? A survey of general practitioners' attitudes in the thrombolytic era.

This study examines the issue of whether to give home or hospital care to patients with suspected myocardial infarction now that the value of thrombolytic therapy has been recognized. A questionnaire survey of 69 general practitioners showed that the majority were aware of the potential benefits of thrombolysis although few thought that these extended beyond six hours after the onset of symptoms. Most would opt for hospital care for patients under the age of 70 years, but would treat older patients with uncomplicated myocardial infarctions at home, depriving them of the opportunity to receive thrombolysis. The admission policies of general practitioners for patients with suspected myocardial infarction merit reappraisal so that thrombolysis can be considered for all patients up to 24 hours after the onset of symptoms.     

Changes in prescribing for terminal care patients in general practice, hospital and hospice over a five-year period

Differences in prescribing between 1981 and 1986 were examined for 100 terminal care patients admitted to a city hospice in each year. Prescribing before and after the patients were admitted to the hospice was also compared for the two years. Between 1981 and 1986 there was a large increase in the number of patients receiving morphine sulphate tablets and a reduction in the numbers receiving Brompton's mixture and other unsuitable analgesics both before and after admission. Contrary to critical opinion, general practitioners showed more acceptable prescribing patterns in both years than hospital doctors. In the hospice more patients received non-narcotic analgesics and parenteral diamorphine by syringe driver in 1986 than in 1981. The need for an organized system of postgraduate training in terminal care is considered.     

Factors influencing the referrals in primary care of asymptomatic patients with a family history of cancer

PurposeTo describe the events and the reasoning that led UK general practitioners to make a direct referral to a genetics clinic for a family history of cancer.MethodsAsymptomatic patients with a family history of cancer and general practitioners who had referred them to a genetics clinic were eligible to participate. Semi-structured interviews incorporating a self-completed questionnaire were conducted with the general practitioners. Questions about the referral had to be framed in general terms as few general practitioners could remember the index case. Individual face-to-face interviews based on a topic guide were conducted with the patients.ResultsThirty-six of 54 eligible general practitioners and 71 asymptomatic patients with a family history of cancer completed the study. General practitioners adopted a reactive rather than proactive role in the provision of genetic services for asymptomatic patients with a family history of cancer. Most general practitioners favored cancer diagnostic clinics as a referral pathway, and made a referral to genetics only when patients or a hospital doctor specifically requested this. More idiosyncratic approaches to the referral decision were also encountered. Updating of skills and knowledge in genetics remained a low priority despite acknowledged inadequacies.ConclusionsReferral guidelines that are practicable in the context of a busy primary care clinic need to be developed if primary care practitioners are to play the major role desired for them in genetics.     

Provision of obstetric care by general practitioners in the south western region of England.

BACKGROUND. Recent government reports have suggested changes to the organization of maternity care in the United Kingdom which may well affect the contribution of general practitioners. AIM. This study set out to document the range of obstetric care provided by general practitioners, their perceived competence at various obstetric procedures, and their beliefs about their role in maternity care. METHOD. A postal questionnaire was sent to a random one in four sample of general practitioners in the South Western Regional Health Authority of England. RESULTS. Of 424 questionnaires sent out, 333 (79%) were returned. Of 303 respondents, 98% provided both antenatal and postnatal care. Of 294 respondents, 45% provided intrapartum care and 27% booked women for home deliveries. Of 117 respondents providing hospital intrapartum care 47% booked 10 or fewer women each year, and most provided little practical intrapartum care. Compared with those providing only antenatal and postnatal care, those who provided intrapartum care believed themselves to be more competent at various obstetric procedures and their perceived competence was significantly correlated to the number of procedures that they performed. Those general practitioners providing intrapartum care made significantly more postnatal visits than those providing only antenatal/postnatal care and were significantly more likely to believe that general practitioners have an important role in labour. CONCLUSION. Many general practitioners in the south western region of England still provide a choice in maternity care for women, and believe that they have an important role in such care. Further work is required to establish what women and their general practitioners believe the latter contribute to maternity care.     

Referring patients to geriatric hospitals: a survey of general practitioners' opinions

Many geriatric day hospitals are under-utilized. A survey of general practitioners' opinions on referral systems to day hospitals in east Surrey produced an 85% response rate. Of the 80 general practitioners who responded 58% referred occasionally, 39% frequently and 4% never. When asked about referring patients directly to the day hospital via the coordinator instead of via the consultant geriatrician, 58% of general practitioners said they would like to have direct access, and 87% were in favour of other health workers involved with the elderly initiating referrals with the general practitioner's consent. Rehabilitation was mentioned as the main reason for referral by 76% of general practitioners, medical assessment by 56% and social care by 48%. Comments received suggested that the hospital day was too long and that early rising associated with attendance caused stress in the elderly attenders. It is concluded that the present system of referral via the consultant is not always satisfactory and that a referral card system which permits general practitioners to refer directly to the geriatric day hospital may increase utilization.     

Characteristics and pattern of care of a diabetic population in mid-Wales.

The pattern of care and demographic features of diabetes in a largely rural Welsh population were investigated before the introduction of measures to improve diabetic care. All data were obtained from general practice notes. Of the population studied 1.01% were identified as diabetic. There were no demographic differences from recently published English studies. Seventy per cent of the diabetic patients had not seen a consultant within the preceding year. The level of surveillance for biochemical control and complications of diabetes was better in those who had had recent consultant care. However, basic surveillance data was missing in many consultant letters to general practitioners. The prevalence of known serious diabetic eye disease (9%) in the study population was similar to that found in a recent study of a structured care system. Proposed improvements in diabetic care must take into account the large number of patients not attending hospital clinics. Communication between consultant clinics and general practitioners must be improved.     

Effects of a community mental health service on the practice and attitudes of general practitioners.

Recent years have seen closer links developing between general practitioners and mental health specialists. A study was undertaken in Manchester to determine the effects of a new community mental health service on the practice and attitudes of general practitioners. Ten doctors had access to the community based psychiatric team over a three year period while another 10 doctors continued to use hospital services. Those with access to the team were significantly more satisfied with the specialist support services, and were more likely to give high priority to community psychiatric nurses and psychiatric social workers working as part of a primary health care team than those without access to the service. Those with access were more willing than those without access to share with psychiatrists the care of patients with chronic neurotic disorders. The community mental health team was considered particularly helpful in reducing the burden posed by patients with neurotic and psychosocial problems, but this resulted in the general practitioners doing less counselling themselves. The study did not find that the new service had an effect on the general practitioners' ability to detect or manage psychiatric illness.     

Factors that influence general practitioners' choice of hospital when referring patients for elective surgery.

To describe the factors that influence general practitioners' choice of hospital when referring patients for elective surgery in three specialties, a postal questionnaire was distributed in January 1991 to 449 doctors who had referred patients to one of six hospitals in the North Western Regional Health Authority. Responses were received from 260 general practitioners (58%). Of the respondents 95% selected 'local and convenient' as a factor that commonly influenced their choice of hospital for at least one specialty and 65% mentioned this across all three specialties. Seventy four per cent mentioned patient preference as influencing choice for at least one specialty and 57% across all three specialties. Only 32% of doctors mentioned waiting times for appointment across the three specialties and 26% waiting times for surgery across the three specialties. When asked to select the single most important factor 'local and convenient' was selected by 33% of general practitioners for a least one specialty, the general standard of clinical care by 28% and waiting time for appointment by 23%. Patient preference was only selected by 6% of doctors as the most important factor. It is of note that 33% of general practitioners perceived there to be no choice of hospital for at least one specialty and 14% thought this to be the single most important influence on choice for at least one specialty. Approximately half the general practitioners (49%) considered it always or often appropriate to give their patients a choice. Most general practitioners received waiting time information from hospitals in their own health district but fewer received such information from hospitals outside their district.(ABSTRACT TRUNCATED AT 250 WORDS)