Implementing choices
Ideally, the well-informed patient, in consultation with family and others, will make key decisions in good time, so that the professionals and carers can arrange everything to everybody’s satisfaction. Too often, however, the default situation arises where a carer is asked by a healthcare professional for urgent approval of a proposed course of action and the patient helplessly complies. This may occur because of a sudden change in the patient’s condition, or the case may be handled by somebody unfamiliar with the situation. Some examples of how this might arise are given in Box 3. Urgent, unplanned admission often reflects a social crisis rather than a medical emergency, but may be avoided with thoughtful advance preparation.6


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The successful implementation of well-made plans depends on good communication between all involved. The GP is best placed to ensure adequate communication among the professionals and lay carers who share responsibility for the welfare of a patient at home.

Awareness and communication among members of the caring team can be improved by a number of mechanisms. These include keeping the patient’s medical record at their home, the timely conveyance of messages to out-of-hours staff and the regular passage of verbal or written updates to district nursing staff, the palliative care outreach team and the GP’s partners and locums. Ideally, communication and continuity of care will be achieved through multidisciplinary meetings.11 The GP must also ensure that any paid carers and others who may be called on in an emergency are sufficiently aware of the care plan to co-operate, within the constraints of confidentiality.

When the GP is unavailable
GPs have a duty of care to their registered patients beyond the periods when they are at work. This can be fulfilled by enlisting help from other healthcare professionals who cover out-of-hours services, who are only responsible for the patient if and when they are called.

Before going off duty, a GP can facilitate the effectiveness of out-of-hours providers by advance planning, such as the provision of a syringe driver at the patient’s home. Boxes of appropriate drugs, such as diamorphine, cyclizine, hyoscine or midazolam, could be prescribed in advance and left at the patient’s house, with appropriate dispensing instructions should they be needed urgently at night or during weekends.11

GPs who fulfil their duty of care by early sensitive exploration of the patient’s views, by regular assessment and monitoring, and conscientious co-ordination of available resources for patients’ benefit, and help them to make and implement choices about their care at the end of life, will make all the difference to the quality of that remaining life.

Dr C. Ruth Butlin is a GP in Alfriston, East Sussex. Competing interests: None declared 

References
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2. DoH. The Patient’s Charter. London, HMSO, 1992.
3. DoH. End of Life Care Strategy. London, DoH, 2008. Available from: www.dh.gov.uk (accessed 27 April 2009).
4. Watson M, Lucas C, Hay A. Adult Palliative Care Guidance. Southwest London, Surrey, West Sussex and Hampshire, Mount Vernon and Sussex Cancer Networks and Northern Ireland Palliative Care Medicine Group, 2006.
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11. Thomas K. Caring for the Dying at Home: Companions on the Journey. Oxford, Radcliffe Medical Press, 2003.
12. Simon C, Everitt H, Kendrick T. Oxford Handbook of General Practice. Oxford, Oxford University Press, 2006.
13. Marie Curie Palliative Care Institute. Liverpool Care Pathway. Available from: www.mcpcil.org.uk (accessed 28 April 2009).
14. DoH. Code of practice, Mental Capacity Act 2005. London, The Stationery Office, 2007.
15. WHO expert committee. Cancer Relief and Palliative Care, Technical Report Series 804. Geneva, WHO, 1990.
16. Ellershaw J, Ward C. Care of the dying patient: the last hours or days of life. BMJ 2003;326:30-4.

Originally published in the June 2009 edition of MIMS Oncology & Palliative Care.