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



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.


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.


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.


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.



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.


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.


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.

This is a preview of subscription content, access via your institution.



Primary palliative care in general practice


German Federal Ministry of Education and Research


Uniform assessment measure


End of life care for frail older patients in family practice


Official grant number


General practitioner


  1. 1.

    Afshar K et al (2015) Hausärztliche Palliativversorgung bei nichtonkologischen Patienten. Schmerz 29(6):604–615

    CAS  Article  Google Scholar 

  2. 2.

    Afshar K, Müller-Mundt G, Schneider N (2016) Wie können Patienten mit chronisch fortschreitenden nicht-onkologischen Erkrankungen erkannt werden, bei denen eine Palliativversorgung sinnvoll ist? Palliativmedizin 17(3):133–138

    Article  Google Scholar 

  3. 3.

    Boockvar KS, Meier DE (2006) Palliative care for frail older adults: ”there are things I can’t do anymore that I wish I could . . . “. JAMA 296(18):2245–2253

    CAS  Article  Google Scholar 

  4. 4.

    Brecher DB, West TL (2016) Underrecognition and undertreatment of pain and behavioral symptoms in end-stage dementia. Am J Hosp Palliat Care 33(3):276–280

    Article  Google Scholar 

  5. 5.

    Chang HT et al (2016) Medical care utilization and costs on end-of-life cancer patients: the role of hospice care. Med (Baltimore) 95(44):5216

    Article  Google Scholar 

  6. 6.

    Chen X, Mao G, Leng SX (2014) Frailty syndrome: an overview. Clin Interv Aging 9:433–441

    PubMed  PubMed Central  Google Scholar 

  7. 7.

    Cronfalk BS et al (2015) Utilization of palliative care principles in nursing home care: educational interventions. Palliat Support Care 13(6):1745–1753

    Article  Google Scholar 

  8. 8.

    Dalal S, Bruera E (2017) End-of-life care matters: palliative cancer care results in better care and lower costs. Oncologist 22(4):361–368

    Article  Google Scholar 

  9. 9.

    De Lepeleire J et al (2009) Frailty: an emerging concept for general practice. Br J Gen Pract 59(562):177–182

    Article  Google Scholar 

  10. 10.

    Ewertowski H et al (2018) Primary palliative care in general practice—study protocol of a three-stage mixed-methods organizational health services research study. BMC Palliat Care 17(1):21

    Article  Google Scholar 

  11. 11.

    Geiger K et al (2016) Caring for frail older people in the last phase of life—the general practitioners’ view. BMC Palliat Care 15:52

    Article  Google Scholar 

  12. 12.

    Harrison-Dening K (2019) Access to specialist palliative care to manage pain in people dying at home: give them a VOICE. Evid Based Nurs.

    Article  PubMed  Google Scholar 

  13. 13.

    Highet G et al (2014) Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): a mixed-methods study. BMJ Support Palliat Care 4(3):285–290

    Article  Google Scholar 

  14. 14.

    Hui D et al (2015) Integration of oncology and palliative care: a systematic review. Oncologist 20(1):77–83

    Article  Google Scholar 

  15. 15.

    Junius-Walker U et al (2018) The essence of frailty: A systematic review and qualitative synthesis on frailty concepts and definitions. Eur J Intern Med 56:3–10.

    Article  PubMed  Google Scholar 

  16. 16.

    Klindtworth K et al (2017) Living and dying with frailty: qualitative interviews with elderly people in the domestic environment. Z Gerontol Geriatr 50(2):151–158

    Article  Google Scholar 

  17. 17.

    Lunney JR et al (2003) Patterns of functional decline at the end of life. JAMA 289(18):2387–2392

    Article  Google Scholar 

  18. 18.

    Lynn J, Adamson DM (2003) Living well at the end of life. Adapting health care to serious chronic illness in old age

    Google Scholar 

  19. 19.

    Maas EA et al (2013) What tools are available to identify patients with palliative care needs in primary care: a systematic literature review and survey of European practice. BMJ Support Palliat Care 3(4):444–451

    Article  Google Scholar 

  20. 20.

    Markle-Reid M, Browne G (2003) Conceptualizations of frailty in relation to older adults. J Adv Nurs 44(1):58–68

    Article  Google Scholar 

  21. 21.

    MAXQDA (2016) Maxqda Software für qualitative Datenanalyse. VERBI Software Consult Sozialforschung, Berlin (1989–2016)

    Google Scholar 

  22. 22.

    Müller-Mundt G et al (2013) End of life care for frail older patients in family practice (ELFOP)—protocol of a longitudinal qualitative study on needs, appropriateness and utilisation of services. BMC Fam Pract 14(1):52

    Article  Google Scholar 

  23. 23.

    Murray SA et al (2004) Developing primary palliative care. BMJ 329(7474):1056–1057

    Article  Google Scholar 

  24. 24.

    Murray SA et al (2005) Illness trajectories and palliative care. BMJ 330(7498):1007–1011

    Article  Google Scholar 

  25. 25.

    Partridge J, Sbai M, Dhesi J (2018) Proactive care of older people undergoing surgery. Aging Clin Exp Res 30(3):253–257

    Article  Google Scholar 

  26. 26.

    Pautex S et al (2010) A common definition of geriatric palliative medicine. J Am Geriatr Soc 58(4):790–791

    Article  Google Scholar 

  27. 27.

    Piers R et al (2010) Palliative care for the geriatric patient in Europe. Survey describing the services, policies, legislation, and associations. Z Gerontol Geriatr 43(6):381–385

    CAS  Article  Google Scholar 

  28. 28.

    Rodriguez KL et al (2010) A cross-sectional analysis of the prevalence of undertreatment of nonpain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients. Am J Geriatr Pharmacother 8(3):225–232

    Article  Google Scholar 

  29. 29.

    Ruggiano N, Perry TE (2019) Conducting secondary analysis of qualitative data: should we, can we, and how? Qual Soc Work 18(1):81–97

    Article  Google Scholar 

  30. 30.

    Statistisches Bundesamt (2015) Bevölkerung Deutschlands bis 2060. 13. koordinierte Bevölkerungsvorausberechnung. Accessed 7 Nov 2019

  31. 31.

    Statistisches Bundesamt (2017) Pressemitteilung vom 19. Januar 2017 – 022/17. Zahl der Todesfälle im Jahr 2015 um 6,5 % gestiegen.;. Accessed 7 Nov 2019

  32. 32.

    United Nations, Department of Economic and Social Affairs, Population Division (2014) World population ageing: 1950–2050

    Google Scholar 

  33. 33.

    Voumard R et al (2018) Geriatric palliative care: a view of its concept, challenges and strategies. BMC Geriatr 18(1):220

    CAS  Article  Google Scholar 

  34. 34.

    Zimmermann GW (2017) 03370 bis 03373: Die Palliativziffern. Der Hausarzt, vol 04/17

    Google Scholar 

  35. 35.

    WHO (2004) Better palliative care for older people. Accessed 7 Nov 2019

Download references


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.

Author information



Corresponding author

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

Ethics declarations

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.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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).

Download citation


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


  • Allgemeinmedizin
  • Geriatrie
  • Palliativversorgung
  • Frailty
  • Versorgungsforschung