GPs’ huge opportunity to provide meaningful palliative care

I’ve been a GP involved in palliative care practice now for about 13 years, but arrived here by an unusual route.
 
I’ve been working in rural medicine since 1994 and spent many years working as an emergency physician and retrieval doctor based in a large regional hospital. After experiencing burnout, I changed tack and ended up coming into palliative care work via rural generalism.
 
I was initially drawn toward the work because I could see there was very little medical presence in this space, and there is an enormous opportunity to be involved at a very profound time in people’s lives. I had been involved in a lot of dying in critical care – and I realised the way in which we care for the dying has a huge impact on the wellbeing of the person who we identify as the patient, and a ripple effect on the lives and experiences of their families, close friends and those who knew them.
 
There is a huge opportunity to provide meaningful care to an entire community through the delivery of good palliative care. I continue to be inspired daily by the privilege of watching and supporting people who are doing very heroic things, very quietly.
 
GPs are ideally placed to deliver excellent palliative care into their communities.
 
Palliative care involves the careful, compassionate application of (usually) very straight-forward clinical medicine in emotionally charged environments. Having a pre-existing therapeutic relationship with a patient and having gained their respect and trust through good medical practice over years beforehand, GPs are in an excellent position to be able to help people navigate the uncertainties of terminal illness – and to support them through the challenges of facing their dying time.
 
The biggest barriers for GPs in providing good palliative care are the time required to have end-of-life care discussions, and to provide good palliative care. This is something which almost invariably requires a big investment in time and emotional energy on the part of the treating doctor.
 
The Medicare Benefits Schedule isn’t currently geared toward that sort of ‘medicine’ and so the practicalities of running a practice and the financial implications can be a cause of difficulty.
 
The other big issue for some is the level of comfort being in a space where ‘the medicine’ is no longer working, and increasingly what we bring to the table are our familiarity with the effects of serious illness, our ability to be calm in crisis, and our ability to support and navigate the dying process with the patient and their family, even when we feel inadequate.
  
Myths also do exist around this area of health. The biggest myths are that increasing fatigue, weakness and tiredness that come in the terminal phase of an illness are primarily due to medications. This can lead doctors, patients and families to ascribe the dying process to the application of medicine rather than understanding that the dying itself causes these things; and some reticence to use appropriate medications to provide effective symptom control.
 
Some GPs remain unnecessarily concerned about the legalities of people dying at home, and prescribing opioids in that setting. The law is clear in each state, and usually simple to follow. Many people can die well at home, supported by family and a diligent GP rationally prescribing opioids and benzodiazepines without any legal concerns at all.
 
To improve access to palliative care and patient outcomes, as well as supporting GPs in delivering this care, the major thing is recognising that dying is a human thing, and medicine is a necessary part of the process. Dying is not a medical process.
 
To support dying people well, we need to have adequate support from a variety of people, including GPs and palliative care specialists, in the community. Nurses, allied health staff, families, friends and informal supports all have a legitimate roll to play in supporting those who are dying in our communities – regardless of where their preferred place of death is.
 
The professional supports need to be appropriately funded – and there are multiple rigorous studies showing that investment in good palliative care returns a clear financial dividend back to healthcare systems in the way of reduced unnecessary tests, medications, and interventions. Well-resourced palliative care services save money for healthcare systems, and well-resourced palliative care systems, involving well-trained generalists and specialists, should be available across the board: from the centres of our major cities all the way out to small remote settlements.
 
There a plenty of excellent resources to support GPs in the work of caring for dying people, and specialist palliative care services are very happy to provide case-based advice and support, education and placements.
 
The care itself is profoundly rewarding, and when it comes together well; there is an enormous impact on individual and community wellbeing.
 
National Palliative Care Week runs 19–25 May.
 
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