Background: Although primary care settings and general practitioners are ideally placed to discuss goals of care and advance care planning with their patients with a life-limiting illness, these conversations are often neglected, even in the terminal stages of both malignant and non-malignant disease. Instead, discussion of code status, living wills, and preferred place of death are often initiated in acute care settings where lack of rapport with the physician or patient incapacity can limit conversations. This narrative review aims to examine the barriers faced by primary care physicians in engaging in these conversations. Methods: Embase and Medline were searched using terms including primary care physicians, advance care planning, terminally ill, and living wills. Reference lists of relevant studies were examined to identify additional studies. Studies were reviewed and analyzed independently by two authors. Results: Fourteen studies were included for analysis. Several barriers to early goals of care discussions were identified. These included physician uncertainty regarding the appropriate timing of discussions; and difficulty allocating sufficient time with patients and families for discussion. Discomfort with estimating prognoses, uncertain disease trajectories, and fears around potential physician-patient conflict were also highlighted. Conclusions: Programs and policies that promote advance care planning as part of usual care, as well as education around disease trajectories and prognosis, particularly for non-malignant disease, may provide increased incentives, confidence and competence for primary care physicians to broach these conversations with patients.
Palliative medicine resident
University of Toronto
Harleen Toor completed her residency in family medicine from the University of Toronto in 2016. She is currently completing a fellowship in Palliative Medicine, also at the University of Toronto.
Thursday, November 23
3:10 PM – 3:35 PM
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