Clinical practice guidelines and general practitioner management of multimorbidity in older adults at the end of life.

A blog post written by Dr. Raechel Damarell

Palliative care and the Australian general practitioner

Australians are living longer lives but many pay for this extended longevity by accruing chronic conditions of ageing such as cancer, dementia, and heart failure into their latter years. [1] This rise in life-limiting conditions is set to place an impossible demand on already stretched specialist palliative care services. [2] Professor Geoff Mitchell has foreseen this eventuality for almost 20 years, periodically encouraging Australian general practitioners to prepare themselves to take on more palliative care in the future. [3-5] While most GPs view palliative care provision as important and a privilege, a considerable proportion of Australian GPs (25–37%) report minimal if any interest or involvement in it. [6] This stance undermines the idea of GPs as providing comprehensive care from 'cradle to grave', and does not align with the World Health Organisation’s Declaration of Astana which calls for palliative care to be both ‘accessible to all’ and an ‘essential component of primary healthcare worldwide.’ [7] Yet general practitioners report practical and emotional challenges to providing palliative care such as difficulty recognising when someone is approaching the end of life and not wanting to impair the trusted relationship or deflate hope by communicating bad news. [8] Some believe they lack the skills or knowledge to do this work. [9] The rising prevalence of 'multimorbidity' in the older population can be a further confounder with GPs reporting more than half of their patients as 'complex' by virtue of their eclectic combinations of interacting and fluctuating conditions on top of psychosocial concerns. [10]

Support to GPs from clinical practice guidelines

Clinical practice guidelines for life-limiting conditions are one tool at the disposal of GPs that might help them overcome some of the challenges they face in managing people with multimorbidity approaching the end of life. Credible guidelines are produced by reputable organisations and informed by eminent specialists in the field and stakeholder representatives. They use transparent and rigorous processes to synthesis the available evidence for clinicians to use in their decision making and in communicating with patients. They should also provide guidance on palliative care if the condition warrants it. Yet single condition guidelines are often written for a broad audience including clinicians working in allied health, nursing, primary care, and secondary specialists. So, knowing the areas of care general practitioners find challenging, how relevant is guideline content to their information needs? 

Multimorbidity acknowledgement within clinical practice guidelines

To answer this question, we analysed the full clinical content of 10 current Australian guidelines for heart failure, dementia, COPD, and cancer published to August 2018. [11,12] We extracted all information on special care considerations for elderly patients, those approaching the end of life, and those with two or more coexisting conditions (i.e., multimorbidity). We also sought statements on the potential burden of illness, treatments, and costs of care to the patient. We were particularly interested to know if guidelines for life-limiting conditions urged clinicians to view their approach to management through the lens of reduced life expectancy and the time required for a medication to have therapeutic benefit. 

The analysis found that most guidelines acknowledge the potential for other conditions ('comorbidities') to co-occur with the life-limiting one. Fewer, however, make specific recommendations, or even general statements, on how to manage any interactions between them. Only half recommended modifying drug treatments in consideration of older age, reduced life expectancy, or to prevent adverse interactions. While concern for quality of life and respect for patient preferences featured strongly, only a few guidelines gave explicit statements alerting clinicians to the high potential for treatment burden with cumulative comorbidity.

Palliative care coverage within clinical practice guidelines

Palliative care content was also extracted and mapped against an established palliative care domain framework (PEPSI-COLA). [13] This process revealed that guidelines are heterogenous in scope and depth of palliative care domain coverage and would be unlikely to augment the knowledge and skills of less confident general practitioners. The role of the general practitioner as a partner in providing palliative care was also not made clear. Clinicians were advised to refer to specialist palliative care without specifying what should trigger a referral. The ‘communication’ needs domain was best addressed, especially in the dementia guidelines, while patient physical and emotional needs were variably covered. Spiritual needs, provision for out-of-hours care, terminal care guidance and aftercare content were scantly covered. Few guidelines addressed areas GPs are known to find challenging such as prognostication and initiating difficult conversations, and only one acknowledged useful prognostication tools such as the surprise question or SPICT.

How might guidelines better serve GPs?

From these findings we conclude that Australian clinical practice guidelines for life-limiting illnesses naturally prioritise the main index condition, directing attention to only the most common comorbidities. However, there may still be leeway to include more condition-agnostic guidance on multimorbidity management. This might be modelled on the ‘guiding principles’ approach now emerging internationally from organisations such as the American Geriatrics Society [14] and NICE [15] and reflected in the RACGP's latest Silver Book for Aged Care. [16]  Where palliative care coverage is concerned, there is clearly an opportunity in coming guideline updates to strengthen GP confidence in providing palliative care by including disease-specific symptom management content as well as addressing prognostication, goals of care conversations, and how GPs and specialist palliative care specialists should work in partnership. We suggest a template covering these important domains might prompt guideline groups to consider each of these points in turn when devising the guideline structure. This would go some way to reducing the considerable variability in depth and scope of coverage that we observed across guidelines.

References

1. Olshansky SJ. From Lifespan to Healthspan. JAMA. 2018 Oct 2;320(13):1323-1324.
2. Bone AE, Gomes B, Etkind SN, Verne J, Murtagh FEM, Evans CJ, Higginson IJ. What is the impact of population ageing on the future provision of end-of-life care? Population-based projections of place of death. Palliat Med. 2018 Feb;32(2):329-336.
3. Mitchell GK, Reymond EJ, McGrath BP. Palliative care: promoting general practice participation. Med J Aust. 2004 Mar 1;180(5):207-8.
4. Schneider N, Mitchell GK, Murray SA. Palliative care in urgent need of recognition and development in general practice: The example of Germany. BMC Fam Pract. 2010 Sep 15;11:66.
5. Mitchell G. Rapidly increasing end-of-life care needs: A timely warning. BMC Med. 2017 Jul 10;15(1):126.
6. Coulton C, Boekel C. Research into awareness, attitudes and provision of best practice advance care planning, palliative care and end of life care within general practice. Canberra, ACT: Department of Health; 2017 Mar.
7. World Health Assembly. Resolution WHA67.19. Strengthening of palliative care as a component of comprehensive care throughout the life course. Sixty-Seventh World Health Assembly, Geneva, 19-24 May. 2014 Jan.
8. Deckx L, Mitchell G, Rosenberg J, Kelly M, Carmont SA, Yates P. General practitioners' engagement in end-of-life care: A semi-structured interview study. BMJ Support Palliat Care. 2019 Sep 3.
9. Herrmann A, Carey ML, Zucca AC, Boyd LAP, Roberts BJ. Australian GPs’ perceptions of barriers and enablers to best practice palliative care: A qualitative study. BMC Palliat Care. 2019 Oct 31;18(1):90.
10. Damarell RA, Morgan DD, Tieman JJ. General practitioner strategies for managing patients with multimorbidity: A systematic review and thematic synthesis of qualitative research. BMC Fam Pract. 2020 Jul 1;21(1):131.
11. Damarell RA, Morgan DD, Tieman JJ, Healey DF. Multimorbidity through the lens of life-limiting illness: How helpful are Australian clinical practice guidelines to its management in primary care? Aust J Prim Health. 2021 Jan 19.
12. Damarell RA, Morgan DD, Tieman JJ, Healey D. Bolstering general practitioner palliative care: A critical review of support provided by Australian guidelines for life-limiting chronic conditions. Healthcare (Basel). 2020 Dec 11;8(4):553.
13. Thomas, K. Holistic Patient Assessment: PEPSI COLA Aide Memoire [Internet] 2009 [cited 2022 Feb 21]. Available from: https://goldstandardsframework.org.uk/cd-content/uploads/files/Library%2C%20Tools%20%26%20resources/Pepsi%20cola%20aide%20memoire.pdf
14. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc. 2012 Oct;60(10):E1-E25. Epub 2012 Sep 19. 

 

 

 

Dr. Raechel Damarell

Research Associate 

Research Centre for Palliative Care, Death and Dying