Caring for frail older patients in the last phase of life

Challenges for general practitioners in the integration of geriatric and palliative care

Versorgung älterer gebrechlicher Patienten in der letzten Lebensphase

Herausforderungen für Hausärzte bei der Integration geriatrischer und palliativer Versorgungsansätze

Abstract

Background

The best possible care for frail older patients at the end of life can require the integration of geriatric and palliative approaches, possibly with different accentuations at different times. General practitioners (GP) are particularly important in this context: they provide patients with low-threshold primary care close to their homes and provide both general palliative care and geriatric services.

Objective

What are the challenges for GPs in caring for frail older patients at the end of their lives?

Material and methods

A secondary data analysis of 52 qualitative interviews was carried out, which were serially obtained at 4 points in time over a period of 18 months with 14 family doctors. In addition, one focus group with five GPs took place. The analysis was carried out according to the principles of grounded theory.

Results

The results show that GPs see the care of frail older patients at the end of their lives through a) the growing number of older people, b) multimorbidity and complexity of the problem areas, c) the integration of geriatric and palliative approaches, d) the high average age of general practitioners and the lack of junior staff and e) the problem of ensuring care in rural areas as a major challenge. The practical transition between geriatric and palliative care is considered by GPs to be fluid and there is a desire for more integration of both disciplines.

Conclusion

In this study GPs perceived a large overlap between geriatric and palliative care. Both approaches should be offered for a selection of patients as a combined service. In the future a systematic network between GPs and geriatricians in practices, clinics, and day clinics will be necessary.

Zusammenfassung

Hintergrund

Die bestmögliche Versorgung für ältere gebrechliche Patienten am Lebensende kann die Integration geriatrischer und palliativer Ansätze notwendig machen – möglicherweise mit unterschiedlichen Akzenten zu unterschiedlichen Zeitpunkten. Hausärzt*innen kommt in diesem Zusammenhang eine besonders hohe Bedeutung zu: Sie stellen die niedrigschwellige, wohnortnahe Primärversorgung der Patient*innen sicher und bieten sowohl allgemeine palliativmedizinische als auch geriatrische Leistungen an.

Ziel der Arbeit

Was sind Herausforderungen für Hausärzt*innen in der Versorgung älterer gebrechlicher Patienten am Lebensende?

Material und Methoden

Es wurde eine Sekundärdatenanalyse von n = 52 seriellen qualitativen Interviews mit 14 und eine Fokusgruppe mit 5 Hausärzt*innen durchgeführt. Die Analyse erfolgte nach den Prinzipien der Grounded Theory.

Ergebnisse

Hausärzt*innen sehen die Versorgung von älteren gebrechlichen Patient*innen am Lebensende durch a) die wachsende Anzahl älterer Menschen, b) Multimorbidität und Komplexität der Problemlagen, c) die Integration geriatrischer und palliativer Ansätze, d) das hohe Durchschnittsalter der Hausärzt*innen und Nachwuchsmangel, sowie e) die Problematik der Sicherstellung von Versorgung in ländlichen Gebieten, stark herausgefordert. Der praktische Übergang zwischen geriatrischer und palliativer Versorgung wird als fließend empfunden, und es besteht ein Wunsch nach mehr Integration.

Diskussion

Von Hausärzt*innen wird eine große Überschneidung zwischen geriatrischer und palliativer Versorgung wahrgenommen. Beide Ansätze könnten für eine Auswahl von Patient*innen als kombinierte Leistung angeboten werden. Zukünftig wird ein systematisches Netzwerk zwischen Hausärzt*innen und Geriater*innen in Praxen, Kliniken und Tageskliniken erforderlich.

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Abbreviations

ALLPRAX:

Primary palliative care in general practice

BMBF:

German Federal Ministry of Education and Research

EBM:

Uniform assessment measure

ELFOP:

End of life care for frail older patients in family practice

FK:

Official grant number

GP:

General practitioner

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Acknowledgements

The funding of ALLPRAX by the Federal Ministry of Education and Research is greatly acknowledged. We graciously thank all GPs for supporting this project and the ELFOP team Jutta Bleidorn, Karin Geiger, Katharina Klindtworth, Gabriele Müller-Mundt and Nils Schneider, for sharing their data.

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Corresponding author

Correspondence to PD Dr. rer. medic. Stephanie Stiel.

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Conflict of interest

S. Stiel, O. Krause, C.S. Berndt, H. Ewertowski, G. Müller-Mundt and N. Schneider declare that they have no competing interests.

Ethical standards

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Stiel, S., Krause, O., Berndt, C.S. et al. Caring for frail older patients in the last phase of life. Z Gerontol Geriat 53, 763–769 (2020). https://doi.org/10.1007/s00391-019-01668-3

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Keywords

  • Family practice
  • Geriatrics
  • Palliative care
  • Frailty
  • Health care research

Schlüsselwörter

  • Allgemeinmedizin
  • Geriatrie
  • Palliativversorgung
  • Frailty
  • Versorgungsforschung