It is commonly assumed that general practitioners (GPs) less often manage the death of a patient under their care as compared to their colleagues in hospitals. However, the shortages in palliative care manpower in places such as Singapore has led to a call for more involvement from family doctors in end-of-life care.

Encountering death is inevitable in the field of healthcare, but with such a pivotal role to play, handling the death of a patient can be very different as a primary care physician, and may prove to be a very challenging responsibility.

Bringing about acceptance

Patients and family members are likely in need of support during this difficult time. More often than not, patients and their families will face anguish, sorrow and pain when deciding on treatment options – or when deciding to go for no treatment at all – for a disease with a terminal prognosis.

“They really want to maintain hope by providing these aggressive treatments,” said Dr. Eric Finkelstein of the Lien Centre for Palliative Care. “But they need to recognise that it’s okay to change course.”

In such instances, primary care physicians can be depended on to educate patients and their families regarding end-of-life care, provide advice, offer emotional or social support and to address challenges that patients may face in coming to terms with a terminal diagnosis – all while taking into account the and expectations.

The importance of communication and shared decision making

“The majority of deaths are usually very peaceful and dignified. The patient just becomes more drowsy, eats less, drinks less,” said Dr Lee Kheng Hock, president of the College of Family Physicians, whose team regularly provides end-of-life care for patients at home.

“To then rush such a person to hospital, in an ambulance with flashing lights, to a very uncomfortable and foreign environment like a hospital bed, surrounded by strangers -- I think it’s not a good way to spend one’s last moments in this world,” he said.

Yet, feelings of shock and fear may lead caregivers and family members to interfere with decisions that are contrary to what patients really want.

Primary care physicians should therefore facilitate in advanced care planning to help patients and their families contemplate, discuss and achieve a shared-decision for the patients’ care. Alternatively, patients may opt to nominate someone with a Lasting Power of Attorney (LPA) to make future health and welfare decisions in their best interests, should they lose the capacity to do so.

These decisions should be carefully documented and kept with the patient’s medical files. GPs should also liaise closely and communicate decisions made with allied health care providers, in order to ensure that the patient’s quality of life is the primary concern.

“Dying is a part of the natural life cycle and you can be comfortable with it, and you can afford the patients an opportunity to die with dignity, to die at their place of choice, to die without pain,” Finkelstein said.

“Those are the things that truly matter.”

Making a decision for the delivery of end-of-life care can be an emotive and difficult process, but by keeping family members up to date with treatment plans and preparing them through empathic communication, primary physicians can help them deal with these challenges.

Caring for those who have suffered a loss

The role of a GP does not abruptly dissipate in the event of a patient’s death.

During bereavement, it is essential for primary physicians to provide support and they may also need to refer family members who are in need of counseling. Additionally, the family members may also become the GP’s patients as they are likely to have neglected their own health needs while dealing with their loss.

Not to mention, the death of a patient can also take a significant toll on the GP, which may inadvertently impact the quality of care provided to other patients.

That said, there is a need for doctors to be able to balance medical duties to the terminally ill patient with a self-awareness regarding one’s own ability to deal with such difficult, emotive issues, and doctors themselves should not hesitate to seek external help if necessary. MIMS

Read more:
Doctors: Coping with patient death
Mastering the art of empathy benefits both doctors and patients
Training nurses to initiate end-of-life conversations with dying patients
End-of-life care: Knowing the difference between saving lives and postponing death