Journal of Palliative Care & Medicine
Open Access

Primary palliative care; Primary care physicians; Symptom management; Advance care planning; Psychosocial and spiritual distress; Hospice eligibility; Patient-centered care; Quality of life

Introduction

Primary care physicians (PCPs) are the backbone of our healthcare system, occupying a pivotal role in the continuum of patient care. They function as the initial point of contact for individuals seeking medical assistance, offering comprehensive healthcare services that encompass preventive care, disease management, and addressing acute medical needs [1]. This central position in the healthcare landscape uniquely positions PCPs to provide primary palliative care, a holistic approach aimed at enhancing the quality of life for patients grappling with serious illnesses. It is important to recognize that palliative care extends well beyond end-of-life care, addressing the myriad physical, emotional, and existential challenges that accompany chronic, debilitating, or lifethreatening conditions.

At the heart of primary palliative care are a set of essential skills and competencies that PCPs inherently possess and further refine through their medical training and practice [2 ]. These capabilities enable PCPs to meaningfully contribute to the well-being of patients with serious illnesses:

Symptom management: PCPs have honed their expertise in diagnosing and managing a wide range of medical conditions. This experience equips them with the ability to assess and alleviate common symptoms associated with serious illnesses, such as pain, breathlessness, nausea, and fatigue [3]. Timely and effective symptom management is paramount for enhancing a patient's comfort and overall quality of life.

Communication skills: Central to the role of PCPs is their capacity to establish and maintain open, compassionate, and patient-centered communication. They excel in conducting sensitive conversations with patients about their illnesses, treatment options, and prognosis. These discussions lay the foundation for building trust, understanding a patient's goals, and making informed healthcare decisions collaboratively.

Advance care planning: PCPs play a crucial role in assisting patients with advance care planning. They help patients document their healthcare preferences, designate healthcare proxies, and complete advance directives [4]. These proactive steps ensure that a patient's wishes are upheld, even in circumstances where they may be unable to articulate their preferences.

Emotional support: Serious illnesses often trigger emotional distress, anxiety, and depression in patients and their families. PCPs are not only adept at recognizing these emotional challenges but are also equipped to provide initial emotional support [5 ]. When necessary, they can make referrals to mental health professionals or support groups, ensuring that the patient's emotional well-being is addressed comprehensively.

Goals of care discussions: Understanding a patient's values, preferences, and priorities is paramount in delivering patient-centered care. PCPs are skilled in facilitating conversations about a patient's goals of care, assisting them in making healthcare decisions that align with their overarching objectives [6 ,7 ]. These discussions empower patients to assert their autonomy and make choices consistent with their values, whether it be pursuing aggressive treatment or focusing on maximizing comfort. While PCPs possess these vital primary palliative care skills, there are instances where a referral to specialty palliative care teams is warranted. These include:

Complex symptom management: In cases where patients experience severe or refractory symptoms that prove challenging to control, a specialty palliative care consultation can provide additional expertise and resources to address these issues effectively.

Psychosocial and spiritual distress: Patients confronting serious illnesses often grapple with intricate psychosocial and spiritual concerns. Specialty palliative care teams are extensively trained to address these dimensions of care, offering counseling, emotional support, and spiritual guidance when necessary [8 ].

Ethical dilemmas: When healthcare decisions become ethically complex or when there is a need for consensus in difficult decision-making, palliative care specialists can provide guidance and facilitate discussions among the patient, family, and medical team, ensuring that ethical principles are upheld.

Uncertain prognosis: In cases where the prognosis remains unclear, or when a patient's goals of care evolve over time, a palliative care consultation can help realign the treatment plan with the patient's evolving wishes and circumstances.

Hospice eligibility: Hospice services are appropriate when patients meet specific eligibility criteria, such as having a limited life expectancy of six months or less. Hospice care is designed to prioritize comfort and enhance the quality of life during the final stages of an illness [9 ]. In conclusion, primary care physicians serve as the first line of defense and support in our healthcare system, offering a broad spectrum of services to patients across various health conditions. Within this role, they are well-positioned to provide primary palliative care, which focuses on enhancing the overall quality of life for individuals grappling with serious illnesses. Through their training and clinical experience, PCPs have honed critical skills in symptom management, communication, advance care planning, emotional support, and facilitating goals of care discussions [10 -13]. Nonetheless, recognizing the appropriate time to involve specialty palliative care teams is equally essential. These teams bring specialized expertise in addressing complex symptoms, psychosocial and spiritual distress, ethical dilemmas, uncertain prognoses, and hospice care. By working collaboratively, primary care physicians and palliative care specialists can ensure that patients receive comprehensive, patient-centered care throughout their illness journey, with a shared commitment to optimizing their comfort and quality of life.

Primary palliative care skill sets

Symptom Management: PCPs are adept at evaluating and addressing the common symptoms associated with serious illnesses. These symptoms may encompass pain, shortness of breath, nausea, and fatigue. Proficient symptom management not only enhances a patient's comfort but also contributes to their overall well-being, enabling them to more effectively participate in their treatment plan. PCPs have honed their communication skills throughout their extensive training and clinical practice. They possess the ability to engage in sensitive and empathetic conversations with patients concerning their illness, available treatment options, and prognosis. These dialogues play a pivotal role in establishing trust, gaining insight into a patient's aspirations, and collaboratively making well-informed decisions. Assisting patients in preparing for future healthcare decisions stands as a foundational component of primary palliative care [14]. PCPs play a pivotal role in guiding patients through the process of documenting their preferences for care, designating healthcare proxies, and completing advance directives. These proactive steps guarantee that a patient's desires are honored, even in circumstances where they are unable to articulate them. Patients grappling with serious illnesses frequently contend with emotional distress, anxiety, and depression. Primary care physicians are ideally situated to provide initial emotional support, offering solace and understanding. When necessary, they can also facilitate referrals to mental health professionals or support groups, ensuring that a patient's emotional well-being receives comprehensive attention. PCPs excel in leading conversations concerning a patient's goals of care [15 ]. By gaining insight into a patient's values, preferences, and priorities, they can effectively align medical decisions with the patient's overarching objectives. Whether the focus is on pursuing aggressive treatment or prioritizing comfort, PCPs are skilled in facilitating these vital discussions.

When to consider referring to specialty palliative care

Primary care physicians (PCPs) possess a remarkable proficiency in evaluating and effectively addressing the array of symptoms commonly associated with serious illnesses. These symptoms, which may encompass pain, shortness of breath, nausea, and fatigue, can significantly compromise a patient's quality of life. PCPs, through their comprehensive training and clinical experience, have honed the ability to provide precise and timely interventions that not only enhance a patient's comfort but also contribute to their overall well-being.

The significance of proficient symptom management cannot be overstated. When PCPs skillfully manage symptoms, they not only alleviate physical distress but also empower patients to actively engage in their treatment plans. By mitigating the discomfort and suffering caused by these symptoms, PCPs foster an environment where patients can better adhere to their prescribed therapies, adhere to medication regimens, and participate more actively in their healthcare decisions. This, in turn, leads to improved treatment outcomes and an enhanced overall quality of life for the patient. The art of communication is a cornerstone of primary care, and PCPs are adept at engaging in sensitive, empathetic, and patient-centered conversations. Their ability to effectively communicate with patients about their illness, the available treatment options, and the prognosis is the linchpin of a trusting and collaborative physician-patient relationship. Through years of extensive training and clinical practice, PCPs have fine-tuned their communication skills, enabling them to navigate challenging and emotionally charged discussions with grace and compassion. These dialogues not only provide patients with crucial information but also offer them a platform to express their fears, hopes, and concerns. In doing so, PCPs gain invaluable insights into a patient's aspirations and values, which are fundamental for shaping a healthcare plan that aligns with the patient's personal goals and preferences. Primary care physicians play an indispensable role in guiding patients through the process of advance care planning, which is a fundamental component of primary palliative care. This multifaceted process encompasses helping patients document their preferences for care, designate healthcare proxies, and complete advance directives.

By assisting patients in these crucial aspects of advance care planning, PCPs ensure that a patient's healthcare wishes are not only known but also legally documented. This ensures that even if a patient becomes incapable of articulating their preferences in the future, their desires for their healthcare are steadfastly honored. Advance care planning, guided by PCPs, empowers patients to have agency over their healthcare decisions, promoting a sense of control and peace of mind. Patients facing serious illnesses often grapple with profound emotional challenges, including distress, anxiety, and depression. Primary care physicians are ideally situated to provide the initial layer of emotional support that patients and their families require during these trying times.

Their ability to offer solace, understanding, and reassurance can make a significant difference in a patient's emotional well-being. PCPs recognize when emotional distress requires specialized care and can facilitate referrals to mental health professionals or support groups. In this way, they ensure that a patient's emotional and psychological needs are addressed comprehensively, contributing to their overall quality of life and resilience in the face of illness.

Discussion

PCPs excel in leading conversations that revolve around a patient's goals of care. By delving into a patient's values, preferences, and priorities, they can effectively align medical decisions with the patient's overarching objectives. These discussions are pivotal in tailoring healthcare plans to meet the unique needs and desires of each patient, whether the focus is on pursuing aggressive treatment to extend life or prioritizing comfort and quality of life. In summary, primary care physicians are not just the first point of contact in healthcare but are also highly skilled in providing essential components of primary palliative care. Their ability to manage symptoms, communicate effectively, guide advance care planning, offer emotional support, and facilitate discussions about goals of care collectively contribute to a comprehensive and patient-centered approach to healthcare. These primary palliative care skills, combined with timely referrals to specialty palliative care when necessary, ensure that patients receive the best possible care, tailored to their individual needs and circumstances.

Conclusion

Primary care physicians are the initial point of contact for many patients facing serious illnesses, and their role in providing primary palliative care is invaluable. They possess essential skills in symptom management, communication, advance care planning, emotional support, and goals of care discussions. However, recognizing when to refer patients to specialty palliative care teams is equally important. Specialty palliative care complements primary care by addressing complex psychosocial-spiritual aspects and providing expert guidance in challenging situations. By working together, primary care physicians and palliative care specialists can ensure that patients receive comprehensive, patient-centered care that maximizes their comfort and quality of life throughout their illness journey.

Acknowledgement:

Not applicable.

Conflict of interest:

Author declares no conflict of interest.

1. Marty CM, Carter BS (2018) Ethics and palliative care in the perinatal world. Semin Fetal Neonatal Med 23: 35-38.

Indexed at, Google Scholar, Crossref

2. Howard E (2006) Family-centered care in the context of fetal abnormality. J Perinat Neonatal Nurs 20: 237-242.

Indexed at, Google Scholar, Crossref

3. Cortezzo DE, Bowers K, Cameron Meyer M (2019) Birth planning in uncertain or life-limiting fetal diagnoses. Perspectives of physicians and parents. J Palliat Med 22: 1337-1345.

Indexed at, Google Scholar, Crossref

4. Kersting A, Wagner B (2012) Complicated grief after perinatal loss. Dialogues Clin Neurosc 13: 187-194.

Indexed at, Google Scholar, Crossref

5. Wilkinson D, de Crespigny L, Xafis V (2014) Ethical language and decision-making for prenatally diagnosed lethal malformations. Semin Fetal Neonatal Med 19: 306-311.

Indexed at, Google Scholar, Crossref

6. Cassell EJ (1982) The nature of suffering and the goals of medicine. N Engl J Med 306: 639-645.

Indexed at, Google Scholar, Crossref

7. Ellis J, Cobb M, O’Connor T, Dunn L, Irving G, et al. (2015) The meaning of suffering in patients with advanced progressive cancer. Chronic Illn 11: 198-209.

Indexed at, Google Scholar, Crossref

8. Daneault S, Lussier V, Mongeau S, Paille P, Hudon E, et al. (2004) The nature of suffering and its relief in the terminally ill: a qualitative study. J Palliat Care 20: 7-11.

Indexed at, Google Scholar, Crossref

9. Duffee CM (2021) Pain versus suffering: a distinction currently without a difference. J Med Ethics 47: 175-178.

Indexed at, Google Scholar, Crossref

10. Duffee C (2021) An intellectual history of suffering in the encyclopedia of bioethics, 1978-2014. Med Humanit 47: 274-282.

Indexed at, Google Scholar, Crossref

11. Thornton R, Nicholson P, Harms L (2019) Scoping review of memory making in bereavement care for parents after the death of a newborn. J Obstet Gynecol Neonatal Nur 48: 351-360.

Indexed at, Google Scholar, Crossref

12. Rusalen F, Cabicchiolo ME, Lago P, Salvadori S, Benini F (2021) Perinatal palliative care: a dedicated care pathway. BMJ Support Palliat Care 11: 329-334.

Indexed at, Google Scholar, Crossref

13. Jansen L, Sulmasy D (2002) Proportionality, terminal suffering and the restorative goals of medicine. Theor Med Bioeth 23: 321-337.

Indexed at, Google Scholar, Crossref

14. Maselli K, Badillo A (2016) Advances in fetal surgery. Ann Transl Med 4: 394.

Indexed at, Google Scholar, Crossref

15. Balaguer A, Martin-Ancel A, Ortigoza-Escobar D, Escribano J, Argemi J (2012) The model of palliative care in the perinatal setting: a review of the literature. BMC Pediatr 12: 25.

Indexed at, Google Scholar, Crossref