National Association for Patient Participation

NI End of life care

08 September 2017

During Palliative Care week, Dr Laurence Dorman reflects on the importance of providing the best possible care for patients with terminal illnesses in the community. While a significant amount of end of life care is provided in hospices and hospitals, most palliative care provision is delivered by family doctors within the community.

Palliative care is a very important element of general practice – in fact, most palliative care is provided locally by GPs. The true value of end of life care was illustrated in the nomination for NI GP of the Year 2016 award. Last September, Dr Emma Casey from Eglinton was presented with the award following a moving and emotive nomination from a patient who reflected on the ‘exceptional’ end of life care provided for her mother.

Like many other GPs, Dr Casey does all she can to provide extra medical attention and treatment for patients in need of palliative care and to give much needed support to families when they need it the most. Unfortunately, family doctors often do not feel that they have enough time to spend with their patients who are terminally ill, and many agree that giving more time to patients is a top priority for improving end of life care.

Dr Laurence Dorman, a GP in Kilkeel Co. Down, has a special interest in palliative care. He has worked in Southern Area Hospice Services, Newry since 2003 and currently works one day per week in the hospice which, through happy coincidence, also provides care for his practice patients in Kilkeel.

I have had an interest in palliative medicine since my early days in hospital training and I feel that GPs as their patient advocate are the perfect clinicians to deliver end of life care.
A while back, my patient, Mr C, was diagnosed with terminal heart failure. He was discharged home from our local hospital - it had been a rocky admission and he had not been expected to survive. Bravely he declined further surgery and opted for end of life care in his own home.

Mr C was lucky - he had a wonderful, attentive family that could care for him at home and he settled into the hospital bed that our fantastic district nursing team had set-up in his living room the day before he left hospital. I called to visit Mr C after my practice closed at 6.30pm that evening - I was determined his first night was going to be a good start to his short stay at home.
Despite feeling nauseous on the trip from hospital to home, Mr C was in relatively good shape – he was able to take small sips of fluids and was in perfect control of his mental faculties. He was delighted to be back home. We quickly went through the packets of medications the hospital had sent home with him and he turned his nose up at the recommended beta-blocker tablets, and I chuckled as I tossed aside the packet of statins supplied by the hospital! We quickly assessed what were the main priorities for the first night and I ensured our twilight nursing team checked him at 11:30 pm, leaving my mobile number in case of any difficulties.

I am in practice almost 10 years now and I have found that in terminal care the best time to perform home visits is before work. We start surgery at 08:30, so I made sure I called with Mr C at 08:00 before my normal practice hours began and called again that evening at 6pm when our surgery had closed.

I continued my early morning visits for a further three days until it became evident that his breathing had deteriorated. It takes time to explain the process of care at the end of life to a family and to manage medication so that your patient is as comfortable and lucid as possible. It is a fine balance and requires daily examinations – yet more home visits – but when done correctly it ensures excellent symptom control.

Mr C required twice daily home visits for the next five days and close co-ordination of care with the district nursing staff who were excellent as ever. He passed away peacefully in his home and I went to the house in the middle of the night to certify him and say my own goodbye. It was very special to have been part of the end of his life and the moments spent with his family after his death were a privilege to experience.

I was lucky and managed to perform a great deal of Mr C’s care in my own time – when patients require end of life care, you often make time available when you possibly can to support and care for them. I also have a very understanding wife! I felt throughout the process the need to take the family with me on the journey. They were always fully informed about any medical decisions I took and so felt empowered and part of the process.

As a GP, having enough time to spend with patients who need it most is so important. In this case, and many others I have been involved in, time and continuity of care were more important than any medicine I gave. Frequently my visits consisted of simply examining my patient and ensuring his comfort – this then embedded a deep sense of security and helped reduce the risk of his family panicking and contacting out of hours or risking readmission to hospital.

General practitioners in Northern Ireland are struggling to cope with the increasing workload that they have and this often results in family doctors being unable to spend the time that they would like with their patients.

RCGPNI has been actively campaigning for increased investment in general practice and a reduction in bureaucracy, all to enable patients to receive the best possible care and services in their local communities. We strongly encourage our political leaders to Put Patients First and support general practice to ensure that services are sustainable for the future and that people receive the quality of care that they deserve.

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