The Family Physician’s Perceived Role in Preventing and Guiding Hospital Admissions at the End of Life: A Focus Group Study

This study sought to explore family physicians' perceptions of their role in providing end of life care and hospital admissions. The researchers determined this was an area in need of study as previous studies suggest that patients report wanting to spend the end of their lives at home and there is variation in rates of hospitalizations by country.

The researchers compared the statistics of studies from different countries, however, when using these statistics, there was a difference in the time frame used by these studies. For example, the US study cited data taken over 18 years and the Belgium study cited data over a 9 year time period. The group discussed the possibility of future studies comparing different countries during the same time frame to provide a more accurate comparison across countries. The group was also interested in the reported decrease in the percentage of end of life hospitalizations in the US. The group posited that the decrease found may be due to patients becoming more involved in the end of life care than in previous years. Also, there has been a shift in the patient-physician relationship and more focus on patient centered care in recent years. The group suggested the cost to benefit ratio for technology has improved in recent years and may contribute to decrease hospitalizations. Additionally, better treatment options were also discussed as impacting rates of hospitalizations.

The group also discussed the significant growth and support of hospice care and end of life care in homes in the US as largely contributing to decreased hospitalization. According to the National Hospice and Palliative Care Organization, the number of people using hospice increased from 495,000 in 1997 to 1.3 million in 2006--an increase of 162% during 10 years.[1] The group also discussed cultural differences in care of the elderly across countries. The US utilizes nursing homes more than in home care of the elderly. Despite the overall decrease in hospitalizations, there was an interesting increase in intensive care use in the last month of life in the US among the elderly. The group discussed time frame and demographic differences between the samples in the studies cited. In addition, there has been a dramatic increase in the ability to manage chronic diseases. Hospitalizations also depend on the physician's role in end of life care. Many physicians may feel more comfortable sending patients to the hospital than providing care at home. The group discussed changes in patient care over the years. Members thought it would be important for physicians to provide care at patients' homes. An article by Peterson et al.[2] indicated that the number of patients receiving house calls has increased in recent years, however, the number of physicians making house calls has decreased likely due to poor reimbursements and increasing overhead costs, requiring physicians to see more patients in the clinic with greater efficiency.

There has been a shift over the years from private practice to group practice as well. This has led to inconsistency of care among group providers versus a single primary care physician albeit theoretically meant to provide more efficiency of patient care

Regarding methodology of the study, the researchers used focus groups to gather their information. The group discussed pros and cons to this type of research to answer the study questions. Qualitative studies are able to provide unique information not easily captured with the use of quantitative measures. The group had concerns with the sample being comprised of established peer review groups. The group discussed the potential of social desirability considering the focus group members knew each other prior to the study and may be less comfortable providing answers that differed from the group. In addition, not all physicians deal with the same number of end of life care cases. For example, physicians who serve a geriatric population may be faced with end of life issues than a physician serving a younger population. Some members mentioned that not all groups had between 8-10 members which is the optimal number recommended focus groups by qualitative researchers. The focus group members received case-studies to guide discussion, however, it would be helpful to add the descriptions in the article. We also discussed whether the questions should have been more open ended to get more information from the focus group participants. The group thought the recording, transcribing, and coding of the data was appropriate for the study.

The results suggest physicians want better support to make end of life care decisions and that they play five key roles in the families' lives. Physicians stated it was difficult to anticipate future scenarios and family doctors may be excluded from the decision process by hospitalists and specialists who have different views. Physicians also felt patients want them to initiate decisions and they view themselves as advisors to patients who should ultimately make the final decision. There was also an underlying frustration on the part of physicians due to "on the go" decision making.

The group discussed the level of comfortability a particular physician may have providing end of life care as important to study The group determined physicians who have good relationships with palliative care professionals are more likely to be comfortable with their decision making in providing end of life care. The study also revealed being available for acute situations determined whether a hospital admission was necessary. If the illness occurred on a weekend, a time when the physician was not available, physicians felt more comfortable with hospitalizations. This reiterated the importance of having an effective team approach to cover care. Lastly, the determination of which provider was responsible for the patient was a major factor in admissions to hospitals. If a physician was able to provide the care needed, hospitalizations were less. Physicians who were more comfortable being advocates and mediators for what is best for their patients, admitted patients to the hospital less.

The authors stated in their discussion, the role of the family physician is complicated. The group discussed what factors make it complicated. Balancing what the patient and family want and the providers' recommendation can be challenging. As the authors state, decisions should be made prior to end of life situations with the patient and family if possible. The group also discussed the value in providers receiving end of life training in medical school and residency. Physicians also must be skilled in facilitating families and patients making decisions.

Overall, the group felt future studies should include focus groups with providers who provide end of life care but whom do not work with each other to reduce the potential for social desirability responding. Future studies should also explore if care is different depending on the type of end of life patient such as care for an aging patient versus a young patient with a terminal illness at end of life. While this study was intended to understand what guides physicians' decisions to hospitalize patients near the end of their life, the article focused primarily on the challenges faced by physicians. The group felt this was equally important, however, the research question was not fully answered and the group was left wondering about the decrease in hospitalizations thought to be addressed in the paper. Overall, the group felt end of the life care is very important topic for discussion by trainees and healthcare providers and with improvements in research design would add more value to readers.

References
1. National Hospice and Palliative Care Organization: NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA, National Hospice and Palliative Care Organization, 2007.

2. Peterson LE, Landers SH, Bazemore A. Trends in physician house calls to Medicare beneficiaries. J American Board of Family Medicine 2012;25:862-8.

Competing interests: None declared