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How should GPs discuss the prognosis of severe COPD with their patients?
- Patrick JP Poels, Tim C. olde Hartman, Tjard R. Schermer, Chris van Weel (31 October 2005)
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Patrick JP Poels, General Practitioner Dep of Family Practice, Radboud University Nijmegen Medical Centre, 6500 HB, The Netherlands, Tim C. olde Hartman, Tjard R. Schermer, Chris van Weel
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Mulcahy et al. reported on the difficulties general practitioners (GPs) face in discussing the prognosis in severe COPD. Knowing which patients want to discuss their prognosis and how to start such a discussion are the main problems GPs experience(1). The authors recommend further research to identify what would help GPs to discuss the prognosis in patients with end-stage COPD. Although this questionnaire survey gives some insight in a few barriers that GPs encounter with respect to discussing prognosis, there are questions arising from the methodology the authors have used. To explore GPs’ attitudes a qualitative approach would have been more appropriate. Qualitative research methods, such as in-depth interviews or focus group studies are nowadays more and more usual. Mixed method research, which combines qualitative and quantitative techniques, would have given the reader more in-depth insight in the complex phenomenon of barriers that GPs experience in discussing the prognosis with their COPD patients(2). Knauft and colleagues reported recently on barriers and facilitators towards end-of-life communication by health care professionals for patients with COPD(3). The results of this mixed method study are interesting because the authors explored both the GP’s and the patient perspective. Only a third of all patients discussed the prognosis with their GP. The facilitators to communicate the prognosis were the same for GPs and patients: a good relationship, trust, GP’s general experience with this kind of illness and patient’s specific experiences with family or friends who have died. On the other hand, the little time available during office hours and the worry that discussing the prognosis will take away patient’s hope were the most important barriers GPs faced. For that reason, we are not surprised that GPs venture their uneasiness in this: in our experience, unless patients suffer severe limitations in their daily functioning, most would rather focus on staying alive than discuss their end of life. Furthermore, patients seem to have doubts about the usefulness – for their personal situation – of continuity of care provided by their GP. However, most patients within general practice value a personal doctor for serious and emotional problems(4). A recent study on recipients’ perspective on ‘breaking bad news’ showed that a patient-centered communication approach, characterized by adjusting and timing of the information according to the patients’ needs, and by encouraging patients to express their feelings and concerns affected the recipients of bad news most favorably(5). This patient- centered communication style was perceived by the patient as the most emotional, least dominant, most appropriate, most available and most expressive of hope in the ability to convey information. This is important for two reasons. First, most patients with COPD suffer from other chronic diseases as well and co-morbidity rather than COPD will determine individual prognosis. Secondly, the communication approach allowed the GP to cope in the best way with the stress, and feelings of anxiety anger, depression and dejection that will inevitably come forward when discussing (poor) prognosis. Therefore, we conclude that GPs feel the need to discuss the prognosis with their patients who suffer from severe COPD. However, GPs are unsure how to convey and breaking the information. More research is needed on how patients would like to see this information being conveyed. Because we know that GP’s communications skills can be improved, we believe that patient-centered instead of disease-centered communications skills should be taught in GP residency. In fact, it is GPs dealing with the individual patients’ perspectives of their situation, determined by COPD, but also by their other morbidity and specific psychosocial context, not the clear-cut prognosis of a disease. This is the most difficult but also the most rewarding aspect of general practice. (1) Mulcahy P, Buetow S, Osman L, Coster G, Bray Y, White P, Elkington H. GPs' attitudes to discussing prognosis in severe COPD: an Auckland (NZ) to London (UK) comparison. Fam Pract 2005;22:538-40. (2) Borkan JM. Mixed Methods studies: a foundation for primary care research. Ann Fam Med 2004;2:4-6. (3) Knauft E, Nielsen EL, Engelberg RA, Patrick DL, Curtis JR. Barriers and facilitators to end-of-life care communication for patients with COPD. Chest 2005;127:2188-96. (4) Schers HJ, Webster S, van den Hoogen HJ, Avery A, Grol RP, van den Bosch WJ. Continuity of care in general practice: a survey of patients’ views. Br J Gen Pract 2002;52:459-62. (5) Smid Mast M, Kindlimann A, Langewitz W. Recipients’ perspective on breaking bad news: How you put it really makes a difference. Patient Educ Couns 2005;58:244-51. Conflict of Interest:None declared |
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