Family Physicians' Involvement in Palliative Cancer Care
Family Physicians' Involvement in Palliative Cancer Care
Family Physicians' Involvement in Palliative Cancer Care
DOI: 10.1002/cam4.5371
RESEARCH ARTICLE
Correspondence
Camilla Zimmermann, Department Abstract
of Supportive Care, Princess Margaret Background: Family physicians' (FPs) long-term relationships with their oncol-
Cancer Centre, 620 University Ave.,
ogy patients position them ideally to provide primary palliative care, yet their
Room 12-300, Toronto, ON, Canada
M5G 2C1. involvement is variable. We examined perceptions of FP involvement among out-
Email: [email protected] patients receiving palliative care at a cancer center and identified factors associ-
Funding information
ated with this involvement.
Canadian Institutes of Health Research, Methods: Patients with advanced cancer attending an oncology palliative care
Grant/Award Number: 152996 clinic (OPCC) completed a 25-item survey. Eligible patients had seen an FP
within 5 years. Binary multivariable logistic regression analyses were conducted
to identify factors associated with (1) having seen an FP for palliative care within
6 months, and (2) having a scheduled/planned FP appointment.
Results: Of 258 patients, 35.2% (89/253) had seen an FP for palliative care within
the preceding 6 months, and 51.2% (130/254) had a scheduled/planned FP ap-
pointment. Shorter travel time to FP (odds ratio [OR] = 0.67, 95% confidence in-
terval [CI] = 0.48–0.93, p = 0.02), the FP having a 24-h support service (OR = 1.96,
95% CI = 1.02–3.76, p = 0.04), and a positive perception of FP's care (OR = 1.05,
95% CI = 1.01–1.09, p = 0.01) were associated with having seen the FP for pallia-
tive care. English as a first language (OR = 2.90, 95% CI = 1.04–8.11, p = 0.04) and
greater ease contacting FP after hours (OR = 1.33, 95% CI = 1.08–1.64, p = 0.008)
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2022 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.
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6214 MOON et al.
were positively associated, and female sex of patient (OR = 0.51, 95% CI = 0.30–
0.87, p = 0.01) and travel time to FP (OR = 0.66, 95% CI = 0.47–0.93, p = 0.02)
negatively associated with having a scheduled/planned FP appointment. Number
of OPCC visits was not associated with either outcome.
Conclusion: Most patients had not seen an FP for palliative care. Accessibility,
availability, and equity are important factors to consider when planning interven-
tions to encourage and facilitate access to FPs for palliative care.
KEYWORDS
cancer, cross-sectional survey, family physicians, palliative care, satisfaction with care
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6216 MOON et al.
and physical and emotional subscales), perception of 3.2 | Current and preferred providers of
medical care total score, and PRFS rating. Factors that medical care
were associated with each outcome at p < 0.25 were en-
tered into the respective stepwise selection procedures; Table 3 identifies the different clinicians currently in-
factors with p < 0.05 were retained in the multivariable volved in provision of non- cancer and cancer- related
logistic regression model. Odds ratios (OR) and 95% medical care and patients' preferences for providers of
confidence intervals (CI) for significant factors were re- such care. FPs were the main providers of non-cancer re-
ported. Analyses were performed on all available data lated acute care (193/254, 76.0%) and non-cancer chronic
and conducted using SPSS version 25 and SAS version medical management (176/254, 69.3%) and were also
9.4. The significance level was set to 0.05. the preferred healthcare providers for both types of care
(218/252, 86.5%, and 221/253, 87.4%, respectively). In
contrast, few FPs were involved in cancer-related care,
3 | R E S U LTS including coordination of cancer care and pain and symp-
tom management for cancer and cancer treatments (0.8%–
3.1 | Participant characteristics 2.0%), nor were they the preferred providers for such care
(2.0%–4.1%). Rather, palliative care clinicians tended to
A total of 832 patients were screened. Of these, 289 be the actual and preferred providers of cancer-related
(34.7%) were ineligible (169 [20.3%] had a language bar- pain and symptom management, whereas oncologists
rier, 55 [6.6%] were too ill to approach, 23 [2.8%] had a were most commonly the actual and preferred providers
cognitive deficit, 17 [2.0%] had no FP, and, for 25 [3.0%], of care for cancer treatment-related symptoms. Few pa-
clinicians asked that patients not be approached). The tients indicated that FPs provided psychosocial palliative
remaining 543 eligible patients (65.3%) were approached care services, including emotional care, advance care di-
at least once. Of these, 280 (51.6%) declined participa- rectives, support for caregivers and family members, and
tion (150 [27.6%] were not interested, 80 [14.7%] felt the arrangement of home-care services (2.8%–6.0%), although
study would take too much time or be burdensome, 44 a somewhat larger proportion of patients preferred FPs to
[8.1%] were not feeling well, and 6 [1.1%] expressed dis- provide such care (12.6%–27.6%). Compared to FPs and
satisfaction with their FP). The remaining 263 (48.4%) oncologists, the largest proportions of patients reported
consented to the study, and 258 (47.5%) completed the that palliative care clinicians were their actual (10.7%–
survey. 29.6%) and preferred (57.8%–68.9%) providers of psycho-
Of those who responded, 89/253 (35.2%; five missing social care.
responses) reported having seen their FP for palliative
care in the last 6 months, whereas 130/254 (51.2%; four
missing responses) had scheduled or planned to sched- 3.3 | Perception of FP's medical care by
ule an appointment with their FP. Table 1 summarizes previous and planned visits to the FP
the demographic and medical characteristics of the 258
participants by each of these two outcomes. There were Table 4 summarizes the number of participants who
no significant differences in demographic or medical agreed or strongly agreed with statements of positive
characteristics between those who had or had not seen perceptions of care received from their FP. Patients were
their FP for palliative care within the last 6 months. most likely to endorse the item “knows me as a person”
Participants who had a scheduled or planned appoint- and least likely to endorse the item “able to provide the
ment with the FP were less likely to be female (p = 0.02) time I need to address all of my problems.” Almost all
and more likely to speak English as a first language statements were more likely to be endorsed by those
(p = 0.02) than those who did not have a scheduled or who had visited their FP for palliative care in the past
planned appointment. 6 months than by those who had not. Feeling that the
Table 2 summarizes enabling factors for patients' visits FP provided sufficient time to address problems was
to the FP. More than 60% of patients indicated that they the only statement that was significantly more likely to
had been with their FP for more than 5 years, and almost be endorsed by those who had a scheduled or planned
half for more than 10 years. Few patients indicated that appointment with their FP than by those who did not
their FP offered home visits during (23/256, 9.0%) or after (OR = 1.29, 95% CI = 1.07–1.55, p = 0.01). The total score,
office hours (21/255, 8.2%) or 24-h telephone support ser- reflecting positive perceptions of overall medical care,
vices (54/255, 21.2%). The majority (147/246, 59.8%) dis- was significantly associated with both having visited the
agreed or strongly disagreed that it was easy to reach their FP for palliative care in the last 6 months (OR = 1.06,
FP or the FP's team after hours. 95% CI = 1.02–1.11, p = 0.002) and having a scheduled
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MOON et al.
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(Continues)
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6218 MOON et al.
T A B L E 1 (Continued)
or planned appointment with the FP (OR = 1.03, 95% appointment included shorter travel time to FPs, 24-h
CI = 1.00–1.07, p = 0.049). telephone support services, and ease of reaching FPs
after hours. In addition, a positive perception of the FP's
care was associated with having seen the FP for pallia-
3.4 | Multivariable factors associated tive care in the last 6 months. Female patient sex was
with previous and planned visits to the FP negatively associated, and English as a first language
was positively associated, with having scheduled or
Results of the multivariable analyses are shown in Table 5. planning to schedule a FP visit. The number of previous
Three FP factors remained negatively or positively as- visits to the palliative care clinic was not associated with
sociated with having visited the FP for palliative care in either outcome.
the past 6 months: travel time to the FP (OR = 0.67, 95% The majority of participants indicated that their FPs
CI = 0.48–0.93, p = 0.02), indicating that the FP offers knew them well and expressed general satisfaction with
24-h telephone support (OR = 1.96, 95% CI = 1.02–3.76, the FP's care. However, there was less endorsement of
p = 0.04), and better perceived care by the FP (OR = 1.05, adequate time to address problems and of confidence in
95% CI = 1.01–1.09, p = 0.01). receiving the best care possible. Moreover, few patients
The following variables were negatively or posi- indicated that FPs provided palliative care services such
tively associated with having a scheduled appointment as cancer- related symptom management, emotional
with the FP: female sex (OR = 0.51, 95% CI = 0.30– care, discussions of advance care directives, support for
0.87, p = 0.01), English as first language (OR = 2.90, caregivers and family, and provision or arrangement of
95% CI = 1.04–8.11, p = 0.04), travel time to the FP home care.8–12 FPs have reported barriers to providing
(OR = 0.66, 95% CI = 0.47–0.93, p = 0.02), and ease of palliative care, including insufficient time22,24; lack of
reaching the FP after hours (OR = 1.33, 95% CI = 1.08– resources including education and training in palliative
1.64, p = 0.008). care22,24; poor integration and communication with other
healthcare providers; and ambiguity about their role in
end-of-life care.13,20–24 Given that FPs' involvement in
4 | DI S C USSION palliative care may enable holistic care, decrease emer-
gency room visits, and increase the likelihood of dying at
In our study, approximately one-third of patients had home,13,32 additional supports and resources are needed
seen their FP for palliative care in the last 6 months, to enable this involvement. These could include training
and half had a scheduled or planned FP's appointment. and education, better integration and communication
Enabling factors associated with having visited FPs for with hospital-based services, and compensation for care
palliative care or with having a scheduled or planned provision.5,13,22
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6220 MOON et al.
Type of medical Family Palliative care Oncologist/oncology Other healthcare Do not receive
care doctor team team providera this carea
Non-cancer related care (e.g., common cold, flu)
Receive 193 (76.0) 2 (0.8) 9 (3.5) 10 (3.9) 40 (15.7)
Prefer to receive 218 (86.5) 18 (7.1) 16 (6.3) — —
Non-cancer chronic medical management (e.g., high blood pressure)
Receive 176 (69.3) 3 (1.2) 8 (3.1) 20 (7.9) 47 (18.5)
Prefer to receive 221 (87.4) 19 (7.5) 13 (5.1) — —
Coordination of cancer care
Receive 5 (2.0) 34 (13.9) 193 (79.1) 4 (1.6) 8 (3.3)
Prefer to receive 10 (4.1) 54 (22.2) 179 (73.7) — —
Pain management for cancer
Receive 3 (1.2) 197 (78.5) 25 (10.0) 1 (0.4) 25 (10.0)
Prefer to receive 5 (2.0) 213 (84.9) 33 (13.1) — —
Symptom management related to treatment for cancer (e.g., nausea from chemotherapy or radiation)
Receive 2 (0.8) 71 (29.0) 140 (57.1) 5 (2.0) 27 (11.0)
Prefer to receive 5 (2.0) 107 (43.3) 135 (54.7) — —
Symptom management for cancer (e.g., nausea, constipation, shortness of breath)
Receive 5 (2.0) 111 (44.6) 106 (42.6) 6 (2.4) 21 (8.4)
Prefer to receive 6 (2.5) 130 (53.3) 108 (44.3) — —
Emotional care related to my cancer (e.g., for anxiety, sadness)
Receive 15 (6.0) 41 (16.4) 9 (3.6) 61 (24.4) 124 (49.6)
Prefer to receive 64 (27.6) 134 (57.8) 34 (14.7) — —
Advance care directives support (planning for the future in case you are no longer able to make decisions for yourself)
Receive 8 (3.2) 74 (29.6) 4 (1.6) 15 (6.0) 149 (59.6)
Prefer to receive 41 (17.2) 164 (68.9) 33 (13.9) — —
Providing support for your caregiver/family
Receive 10 (4.0) 27 (10.7) 7 (2.8) 19 (7.5) 189 (75.0)
Prefer to receive 50 (21.8) 145 (63.3) 34 (14.8) — —
Arranging home care and related services (e.g., community care access center)
Receive 7 (2.8) 49 (19.8) 46 (18.6) 30 (12.1) 115 (46.6)
Prefer to receive 30 (12.6) 154 (64.7) 54 (22.7) — —
a
Response options provided only for “Receive.” Number of participants who did not indicate a medical care provider: for non-cancer related care, 4 “receive”
and 6 “prefer” participants; for non-cancer medical management, 4 “receive” and 5 “prefer” participants; for coordination of cancer care, 14 “receive” and 15
“prefer” participants; for pain management for cancer, 7 “receive” and 7 “prefer” participants; for symptom management (cancer treatment), 13 “receive” and
11 “prefer” participants; for symptom management (cancer symptoms), 9 “receive” and 14 “prefer” participants; for emotional care, 8 “receive” and 26 “prefer”
participants; for advance care directions, 8 “receive” and 20 “prefer” participants; for caregiver/family support, 6 “receive” and 29 “prefer” participants; and for
home care arrangements, 11 “receive” and 20 “prefer” participants.
Visited family physician for palliative care in last 6 months, n (%) Scheduled/plan to schedule appointment with family physician, n
agree/strongly agree (%) agree/strongly agree
Perceptions of medical
care Obs N Yes No OR (95% CI) p Obs N Yes No OR (95% CI) p
I am satisfied with the care 248 68 (78.2) 100 (62.1) 1.37 (1.10–1.69) 0.004 250 93 (72.7) 77 (63.1) 1.13 (0.94–1.35) 0.20
I get from my Family
Doctor
I am confident that I am 239 57 (67.1) 89 (57.8) 1.25 (1.03–1.51) 0.03 241 79 (63.2) 68 (58.6) 1.18 (0.99–1.41) 0.06
receiving the best possible
care from my Family
Doctor
My Family Doctor's role in 249 66 (74.2) 90 (56.3) 1.46 (1.16–1.82) 0.001 250 84 (66.1) 73 (59.3) 1.17 (0.96–1.42) 0.11
my healthcare is clear
My Family Doctor is able to 249 60 (67.4) 80 (50.0) 1.42 (1.15–1.73) 0.001 250 81 (62.8) 60 (49.6) 1.29 (1.07–1.55) 0.01
provide the time I need to
address all of my problems
My Family Doctor knows me 250 72 (82.8) 119 (73.0) 1.35 (1.05–1.74) 0.02 251 103 (79.8) 89 (73.0) 1.21 (0.97–1.50) 0.08
as a person
My Family Doctor provides 250 65 (73.0) 103 (64.0) 1.19 (0.96–1.49) 0.11 252 91 (71.1) 79 (63.7) 1.14 (0.93–1.40) 0.20
me with prompt care
My Family Doctor is available 253 66 (74.2) 99 (60.4) 1.32 (1.05–1.66) 0.02 254 82 (63.1) 85 (68.5) 1.14 (0.93–1.40) 0.22
for the services I want
him/her to provide
Satisfaction with care total 253 27.8 (6.8) 24.6 (7.6) 1.06 (1.02–1.11) 0.002 254 26.6 (7.5) 24.8 (7.5) 1.03 (1.00–1.07) 0.049
score, mean (SD)
Note: OR indicates per-level increase in agreement. P-values are derived from univariable binary logistic regression analyses that regressed each item on each outcome. The seven perception items were combined into
a single score reflecting perceptions of the family physician's medical care. Five participants did not have a rating for the “visited family physician for palliative care in last 6 months” outcome, and four did not have a
rating for the “scheduled/plan to schedule appointment with family physician” outcome.
Abbreviations: CI, confidence intervals; Obs N, observed sample sizes in descriptive analyses; OR, odds ratios; SD, standard deviation.
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T A B L E 5 Multivariable factors associated with previous and planned visits to family physician
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