08 • Careers


CARING TO THE END


Dignity and compassion are key for GPs looking to develop a special interest in palliative care


W


HAT makes for a “good death”? This question seems to have been up for increased discussion in recent years as the medical profession and its regulators consider issues surrounding end-of-life care more carefully. Updated guidance from the General Medical Council emphasises the need for high quality treatment,


compassion and dignity, while making decisions that are clinically complex and often emotionally distressing. For patients, the ability to control pain, to understand what can be expected and to have a choice over where death occurs have also been identifi ed as important factors. Palliative medicine specialists play an important role in providing care


for patients with complex physical, psychological, social and spiritual support issues. However, the majority of care for those nearing the end of their lives is provided by other clinicians , with 40 per cent of all UK deaths occurring under the care of GPs, at home or in care homes. A GP with an “average list” of 2,000 patients will have 20 die each


year, but that fi gure rises for practices with a high number of elderly patients. GPs looking after residential and nursing home patients will also be providing palliative care for large numbers of patients in the GP practice setting.


While the number of GPwSIs in palliative care remains relatively small, the fi eld is expanding and opportunities look set to increase.


Entry and training GPs looking to develop a special interest in palliative care will need to undertake further training, taking into account prior learning and experience. Options include: • Working under the supervision of a palliative medicine consultant in community/hospice/hospital setting


• Attending recognised meetings and lectures/tutorials • Undertaking a recognised university course leading to diploma/ masters in palliative medicine


• Working in palliative care during a GP vocational training programme.


Most GPwSIs will also undertake accredited communication skills training such as the advanced communication skills training run by the National Cancer Action Team.


The RCGP identifi es the skills for a GPwSI palliative care to include: • Clinical management and symptom control of patients with cancer


and non-cancer end stage illnesses


• Provision and monitoring of drug therapies for symptom control • Managing emergencies in palliative care • Care in the dying phase/fi nal days of life • Communicating with patients nearing the end of life and their carers/ families


• Support and bereavement care for carers/families • Provision of care for the elderly in care homes, including those with cognitive impairment/dementia


• Adequate knowledge of the Mental Capacity Act and other relevant health law


• Knowledge of organisations and access to services related to palliative care in-hours and out-of-hours (OOH)


• Knowledge of strategy, policies and tools related to end-of-life care • Management, leadership and audit skills.


GPwSIs must be sensitive to the particular needs of their vulnerable patient group and, as the GMC guidance states, ensure patient dignity is maintained at all times. An ability to work within a multidisciplinary team is also key, as well as tactfulness and a willingness to respond to crises at short notice.


GPwSIs will usually have regular appraisals with a local consultant in


palliative medicine, which often includes case note reviews, observed clinical practice, logbooks of patients seen and a portfolio of educational events attended or led.


The job When it comes to the fi nal days and hours of life (in response to the removal of the Liverpool Care Pathway for the Dying), the Leadership Alliance for the Care of Dying People has identifi ed fi ve key principles for doctors working in palliative medicine:


1. The possibility that a person may die within the next few days or hours is recognised and communicated clearly.


2. Sensitive communication takes place between staff and the dying person, and those identifi ed as important to them.


3. The dying person, and those identifi ed as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.


4. The needs of families and others identifi ed as important to the


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