Early identification of the end-of-life in primary care setting.

Dear Professor Jeffrey Scherrer,

We read with great interest Deckx et al.’s (1) article on approaches to initiating end-of-life (EOL) conversations. We were impressed by the GP involvement in EOL care and commend this; with an expected increase in the numbers of deaths (2), these conversations need to become a generic skill.

In view of the improved life quality observed in patients who had early identification of their EOL (3), we advocate that early identification is essential. Given the GP’s familiarity with their patients, and their role in regularly reviewing their care, GPs are in an ideal position to initiate EOL care. However, the article did not suggest how patients can be identified earlier in the disease process.

There are many approaches to early identification of EOL, which enable the initiation of appropriate conversations and palliative care referrals at a suitable time.

One such example is the Gold Standard Framework (GSF), a care programme, together with the GSF Prognostic Indicator Guidance (4). The guidance incorporates the ‘surprise question’ (would it be surprising if the patient died within the next 12 months) as well as general and specific indicators of functional decline, to prompt the clinician to identify EOL in a patient. In practice, research (5) suggests that GSF use among GPs has been beneficial. It has been found to increase the practitioner’s awareness of EOL issues as well as to boost their confidence in and ability to deliver high-quality care to meet the changing needs of their patients (5).

The RADPAC is another tool, developed specifically to aid GP in this field. It combines practice experience with scientific evidence to present prognostic indicators similar to GSF (6). This aims to improve the practitioner’s identification of EOL in patients with heart failure, chronic pulmonary disease and malignancy.

In addition, direct training programmes may also improve efficiency.

A randomized control trial (7) compared the effects of a single-day training programme for GP, consisting of RADPAC implementation and education into providing structured anticipatory palliative care, against a control group over a period of 1 year. Trained practitioners identified significantly more patients than their untrained colleagues (median of 3 palliative patients compared with 2; P < 0.046). Moreover, these identified patients received significantly more contact time with their GP and had undergone fewer hospital admissions than patients of untrained practitioners. Overall, training significantly increased the prevalence of multidimensional care, specifically attributed to attention to psychological and spiritual needs of the patient.

In conclusion, we suggest that, in addition to providing GPs with new tools to aid the identification process, adequate time and training be delivered to aid practitioners in utilizing these approaches and identifying EOL early. This should lead to improved life quality for patients suffering from terminal diseases.