For those of us with a loved one needing palliative care, a caring and attentive family doctor can make a world of a difference. Palliative care encompasses a holistic approach to providing relief to persons suffering from a condition that is not curable. In Sri Lanka alone there are an estimated 91,000 people per year who require palliative care services. With this in mind, we reached out to the College of Palliative Medicine of Sri Lanka to ascertain the role of the general practitioner (GP) in these situations. We spoke to senior family physician Dr. K. Chandrasekher, who is also the Past President of the College of General Practitioners of Sri Lanka, Treasurer of the Palliative Care Association of Sri Lanka, and a Council Member of the College of Palliative Medicine of Sri Lanka.
Who are those who require palliative care?
Among those who are suffering from a lifelong illness, the majority of those who require palliative care are those who have a non-communicable disease such as chronic cerebrovascular and cardiovascular disease, chronic renal or respiratory failure, patients with cirrhosis and liver failure, advanced cancers, Alzheimer’s disease, Parkinson’s disease, and dementia, etc., with a minority suffering from communicable diseases including HIV/AIDS, and chronic infections. Patients who need palliative care can be of any age. We have an ageing population in Sri Lanka. It’s estimated that 12.3% of the population is aged 60 or older, thus making us one of the countries with the highest proportion of older adults in South Asia. With this demographic transition from a youth bulge to an ageing society, it is evident that elderly, terminally ill patients will require most of our palliative care resources in the future, said Dr. Chandrasekher.
Role of the GP in providing palliative care
Palliative care can be provided in many settings. Most of these patients receive such services through hospitals, outpatient departments and clinics, community programmes, and hospices. Most often a team of healthcare professionals comes together in providing these services and among them, the GP plays a pivotal role. These patients move in and out of hospitals and eventually many are sent home in the final stages of their illness.
It is important to view death as a process rather than an event. For some patients, it might be a long journey compared to others. Statistics from developed countries show that only 10% have instant death while most tend to suffer a lingering death. This can lead to great emotional turmoil and suffering not just for the dying patients but also for their loved ones who care for them, acknowledged Dr. Chandrasekher. Some of them might opt to spend their sunset years in the comforts of their home. Thus, the family physician plays a key role, as they are the closest to the family and the community at large and hence the easiest to access.
Sri Lankan GPs work almost exclusively in the private sector islandwide and attend to almost 51% of patients seeking primary care facilities. Continuity of care is also a critically important dimension of general practice. Continuity extends to all episodes and more than one generation in the family. The GP can aid in coordinated care as it requires a multidisciplinary team approach and can assist in channelling the required multidisciplinary medical expertise promptly. In addition, when required, home visits can easily be arranged by GPs and they are accustomed to the patients’ needs and the resources available to them as they have a long-standing rapport with the patient and their family. Furthermore, they have access to the medical records of the patient at any given time.
Do’s and Don’ts in patient palliative care
As a senior family physician, Dr. Chandrasekher believes that all GPs should have a clear and insightful appreciation of the basics of palliative care. This understanding will help them deliver quality care to the patients needing palliative care in both an outpatient setting and at home. They should know these do’s and don’ts while managing these patients and know when to seek the advice of specialists.
The six essential elements of palliative care as described in the Journal of Palliative Medicine are:
- Integrated teamwork
- Management of pain and other physical symptoms
- Holistic care
- Caring, compassionate, and skilled providers
- Timely and responsive care
- Patient and family preparedness
These essential elements of care fall under the umbrella of physical care, medical treatment, psychological care, social care, and spiritual care.
As stated above, the GP needs to integrate and coordinate these facets of holistic care by other professionals. Holistic care is the essence of family medicine. Viewing the wellbeing of the patient holistically and adopting a patient-centred care approach rather than a disease-centred care approach is very important in the field of family medicine
A nurse or a family member can aid the GP in many ways. In instances where a nurse is not available, a family member or a volunteer could be trained in certain areas to assist the GP. Often, the role of the nursing staff is even more important than the role of doctors in the care of such patients since they spend more time with the patient when compared to the GP and the specialists who are in attendance, said Dr. Chandrasekher.
Relief of pain and symptomatic management of other problems are extremely important. This too can be efficiently managed by the GP with the support of others such as the nurse and family members. The GP may need help from specialists when necessary.
In a paper titled “Palliative care; the role of family physicians” by Ramanayake et al, it was stated: “A GP may have to manage a whole lot of symptoms such as weakness, fatigue, drowsiness, loss of appetite, nausea and vomiting, mouth problems, dysphagia, hiccups, ascites, constipation and diarrhoea, bedsores, cough and breathlessness, bleeding, edema, and some psychological conditions such as anxiety and depression as well. Diet is another aspect of physical care. The primary care doctor should advise the caregivers to give adequate food and liquid to the patient in a form that can be easily swallowed and digested by the patient.”
Being a caring, compassionate and skilled provider is an important trait that every GP should develop. One way to acquire this trait is to become empathetic towards the patient by regarding the patient as your father, mother, or sibling. This trait will enable a GP to provide medical treatment that is packaged with compassion and kindness. The GP should also help to inculcate this trait among the family members of their patients and train them to carry out simple tasks to make the life of the patient comfortable both from physical and mental perspectives.
The GP is best suited to provide timely and responsive care to the patient. Depending on the circumstances, guidance can be provided over the phone or in person. GPs can become very good at deciding what type of timely and responsive care is needed, since they get to know their patients well. The patients, with time, begin to regard their GP as a friend, advisor, and counsellor. As most of the GPs live in the locality, they find it easier for them to attend to the patient’s problems at their earliest. This places them in an apt position to help in the most difficult task of patient and family preparedness for the outcome and how to face it. Dr. Chandrasekher concluded: “In this journey called life we are all just walking each other home”.