Care Beyond Cure: How GPs can support patients from diagnosis to end of life

Clin Asst Prof Victoria Wong, Consultant, Division of Supportive & Palliative Care, National Cancer Centre Singapore

 

The established, trusting relationships between general practitioners (GPs) and their patients serve as a strong platform for delivering timely palliative care in the community, through all stages of illness. Discover the various ways that GPs can holistically care for cancer patients, as well as courses that can help develop skills and confidence in this area.
 

INTRODUCTION

General practitioners (GPs) are often the first point of contact for patients seeking treatment or advice for acute and chronic medical conditions. They provide holistic care not only for the patient but also their family members and loved ones.

In Singapore, the demand for palliative care is projected to increase with the country’s rapidly ageing population, increased life expectancy and growing burden of chronic diseases. The evolving healthcare landscape will require GPs to manage patients within creasingly complex medical needs in the community.

Ideally, a GP provides continuous medical care throughout a person’s life from cradle to grave. They play an increasingly important role in delivering timely palliative care in the community that supports patients through every stage of their illness, given their broad medical knowledge and established relationships with patients and their families.

The importance of palliative care was also highlighted by the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) which advocated that for all to have access to palliative care, it must be made available in the community.

PALLIATIVE CARE IN SINGAPORE

What is palliative care?
As defined by the World Health Organization, palliative care is a holistic approach aimed at improving the quality of life of patients, both adults and children, and their families who are facing the challenges associated with life-threatening illnesses.

Palliative care involves the early identification, thorough assessment and treatment of pain and other physical, psychosocial or spiritual issues that may arise during the course of illness.¹

Benefits of palliative care
Often misunderstood, palliative care does not startonly at the end-of-life (EOL). It can be integrated early in the illness trajectory, alongside active treatment (Figure 1).

Early access to palliative care can help improve qualityof life, enhance mood and even prolong survival^.2,3 It can also reduce unplanned hospital 30-day readmissions, particularly among patients receiving home hospice care.⁴

Alignment with our nationwide approach
The community palliative care delivery approach aligns with the vision of the Ministry of Health’s Healthier SG initiative, which emphasises empowering individuals to take charge of their health, supported by a strong network of GPs and the three healthcare clusters.⁵

Both Healthier SG and palliative care share a common goal of achieving optimum quality of life for patients and their families.

IMPORTANCE OF EARLY GP INVOLVEMENT IN PALLIATIVE CARE FOR CANCER PATIENTS

Launched in 2023, the National Strategy for Palliative Care’s vision is to ensure that all Singaporeans and their caregivers have access to quality palliative care services – delivered by trained professionals and supported by a conducive palliative care environment.

As primary care providers, GPs are well-placed to support cancer patients throughout the course of their illness. The strong, trusting relationships GPs build with patients put them in a good position to identify those who may benefit from palliative care and ensure timely referrals to appropriate services.

Some of the key areas GPs can play a part in to deliver palliative care for cancer patients include:

1. Early identification and initiation of palliative care

Recognising patients who have palliative care needs can allow patients to access palliative care in a timely manner. Assessment tools such as GSF (Gold Standards Framework), NECPAL (Necesidades Paliativas) and SPICT (Supportive and Palliative Care Indicators Tool) can be used to help with the identification of patients who have palliative care needs.

2. Symptom management

Monitor and continue with the management of symptoms such as pain, nausea or breathlessness in cancer patients, ensuring optimal symptom control.

3. Care coordination and communication

The GP, being the central point of contact, is able to help ensure a seamless transition of care between hospital and community services. They can also facilitate serious illness conversations and advance care planning, delving deeper into exploring patients' EOL wishes and goals of care with patients and their families in accordance with life goals they hope to achieve. While these conversations can be challenging, they are important to ensure the care decisions align with the patient’s personal values. It also helps to foster trust between the healthcare provider, patients and families.

4. Family support

Provide emotional and practical support, such as counselling, respite care, caregiver training and bereavement support to patients and their families throughout the cancer journey. When a patient passes away, the family and loved ones continue to be supported by GPs in the bereavement phase such as monitoring them for grief or depressive symptoms and referring them for appropriate support.

EMPOWERING GPs TO PLAY A BIGGER ROLE IN PALLIATIVE CARE

In a recent qualitative study conducted by SingHealth Polyclinics, some of the challenges faced by GPs in providing palliative care include a perceived limited role, resource constraints, patients’ perceptions of GP capabilities and emotional challenges.

To address these challenges and needs, various opportunities and programmes have been introduced locally to support and equip GPs with the necessary skills and resources to deliver palliative care in the community.

GPs who wish to seek further training in EOL care for patients with end-organ failures can explore the Cardiac Supportive Care and Renal Supportive Care Courses.

The Lien Centre for Palliative Care - Singapore Hospice Council (LCPC-SHC) Postgraduate Palliative Care Course for Doctors, Serious Illness Conversations workshops by LCPC, and the Graduate Diploma in Palliative Medicine, National University of Singapore (NUS) are available to support GPs in building confidence and competence in palliative care and increasing its accessibility to cancer patients.

For more information on generalist supportive and palliative care courses for GPs, please refer to Table 1.

When more GPs develop competency and confidence in providing palliative care for cancer patients, they will play a vital role in improving the accessibility of palliative care in the community across Singapore.

GPs can help ensure patients receive timely and tailored care, benefitting not only patients and their families but also the broader healthcare system over time.

HOW GPs CAN REFER A PATIENT

To refer a patient who requires palliative care, GPs can contact the Division of Supportive & Palliative Care, National Cancer Centre Singapore at:

Tel: 6436 8288
Email: gpnetwork@nccs.com.sg

GP Appointment Hotline: 6436 8288
 

REFERENCES

1. Palliative care. https://www.moh.gov.sg/news-highlights/details/white-paper-on-healthier-sg. Accessed on 20/3/2023.
2. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM 2010; 363 (8):733–742
3. Tassinari D, Drudi F, Monterubbianesi MC, et al. Early palliative care in advanced oncologic and non-oncologic chronic diseases: a systematic review of the literature.Rev Recent Clin Trials 2016; 11 (1):63–71.
4. Ranganathan A, Dougherty M, Waite D, Casarett D. Can palliative home care reduce 30-day readmissions? Results of a propensity score matched cohort study. JPalliat Med. 2013 Oct;16(10):1290-3. doi: 10.1089/jpm.2013.0213
5. White paper on Healthier SG. https://www.moh.gov.sg/news-highlights/details/white-paper-on-healthier-sg. Accessed on 20/3/2023.

Clinical Assistant Professor Victoria Wong is a physician in the Division of Supportive and Palliative Care, National Cancer Centre Singapore. She obtained a Bachelor of Arts degree from the National University of Singapore where she majored in Psychology and Statistics.

She then obtained her medical degree from the University of Sydney in 2006 and completed her internship at the Royal Prince Alfred Hospital (Sydney). She returned to Singapore in 2008 and continued her medical career in Singapore General Hospital. She completed her Graduate Diploma in Family Medicine in 2015 and Master of Medicine in Family Medicine in 2016. She then specialised in palliative medicine and obtained her specialist accreditation in Palliative Medicine in 2020.

She is a faculty member in the MMed Family Medicine College Programme and is a tutor to the trainees. She also has a special interest in quality improvement activities and supporting the promotion of awareness of challenges in adolescents and young adults with cancer.