GPs’ Role at the End of Life

Key Focus Areas:

• Person-Centred Care:
  • Support wellbeing and quality of remaining life.
  • Respect the person’s values, goals, and treatment choices.
• Proactive Clinical Care Planning:
  • Anticipate and provide care as the person’s condition deteriorates.
  • Shift goals of care from treating illness to comfort and managing death.

Engagement with End-of-Life Issues:

• Anticipate and plan to minimize predictable problems.
• Improve care and quality of life for patients and carers.
• Ensure high-quality handovers for continuity of care, especially in RACFs.

Role of Rural GPs:

• Continue providing care as patients move between home, RACFs, and rural hospitals.
• Address lack of patient access to community nursing, specialist palliative care, and home care equipment.

Increasing Demand for GP Care at End of Life:

• Ageing population.
• Technological advances extending life.
• Growing number of patients with progressive chronic diseases and disabilities.
• Patients avoiding unwanted medical and hospital treatments.
• Preference for palliative care at home or in RACFs.
• Gaps in community end-of-life care services.
• Increased patient awareness of advance care planning.

Skills Required for End-of-Life Care:

• Systematic chronic disease management.
• Person-centred care and communication.
• Shared decision making and goals of care.
• Supporting carers and family.
• Dealing with uncertainty.
• Anticipating likely events.
• Clinical care planning, including crisis planning.
• Team care participation and coordination.
• Using tools and resources to supplement knowledge and skills.
• Referrals and shared care with specialists and local team-based support services.
• Use of peer support and training.

Barriers for GPs:

• Uncertainty and lack of knowledge about prognosis, illness trajectory, and terminal phase of advanced chronic diseases (e.g., cancer, heart failure, dementia).

Importance of GP Awareness:

• Awareness of illness trajectories allows anticipation of likely events.
• Facilitates practical planning for end-of-life care.