The survey was handed out to all GP residents working in Paris and its suburbs (“Île-de-France”) (n=1172). About them, 196 did not fulfilled the inclusion criteria (previous 6- months rotation in GP office and not in hospital ward). Among the remaining 976 potential responders, 525 (53.8 %) accepted to answer. The remaining residents refused to fill out the survey after being informed (n= 452) or used to work in a general practice setting during the study period (n=195).
Patients’ end-of-life care during their current rotation
354 (67.4%) residents were satisfied with the quality of end of life care during their rotation. However, 315 (60%) thought that palliative care should have been implemented earlier. Moreover 74.1% of them thought that the end-of-life care could have been improved. Possible axis for improvement were both somatic pain (64%) and anxiety (56.6%) management and psychological support for the patient and his relatives (See figure n°1)
The period of time immediately preceding death was particularly difficult since 239 residents (45.4%) considered that patients’ physical suffering was inefficiently treated. Finally, 58.5% of the GP residents felt that their own psychological distress was not correctly taken care of.
Parameters associated with the perception of end-of-life care quality
Four Types of parameters are associated with resident’s evaluation of end-of-life care quality: end-of-life care implementation, quality of patient’s complaints’ support, residents’ perception of their management by senior physicians and personal difficulties regarding end-of-life care. Details are in table 1.
Difficulties met by residents while caring for dying patients
- Perception of unreasonable obstinacy (lack of communication between physicians)
313 residents (59.6%) consider having witnessed unreasonable obstinacy in the care of their hospitalized patients. They considered it was obstinacy because of the severity of the clinical picture (65.9%) and because of the severity of the prognosis short-term (61.7%). For 15.1% of residents obstinacy was revealed by the refusal to follow a previously stated therapeutics’ limitation.
- Communication with senior physicians
Among residents who felt having witnessed unreasonable obstinacy, only 167 (53.4%) felt free to express their disagreement.
- Communication with patients
210 (40%) participants disclosed having difficulties to talk about death with their dying patients. Likewise 199 (37.9%) residents have difficulties talking about these things with patients’ relatives. Both difficulties are associated in 63.2% of cases.
As expected the wish to stop caring for dying patients in the future and communications difficulties are linked (cf. Table 2a and 2b). Conversely wishing to have an end-of-life activity in the future is associated with a lesser risk of communication difficulties. (cf. table 2a and 2b).
- Therapeutic difficulties
Only 114 (21.7%) residents say having no difficulties using and adapting analgesic and sedative drugs used in end-of-life care. Also, 46.9% of the residents admit their fear to shorten the life of these patients because of the use of sedative and analgesic treatments. Moreover 63.4% (n=246) of them considered that this fear to shorten life may have limited the adaptation of end-of-life care treatments. In the same fashion, fear to shorten life was associated with the feeling of a lack of anxiety management for dying patients (p=0,007).
- Need for stronger supervision
In this work, 227 (52.8%) residents were satisfied with the supervision form senior staff members for the end-of-life care.
Among residents considering that supervision could improve (n=248), 59.7% of them wished for more assistance in the therapeutic aspect of end-of-life care.
The quality of supervision is associated in our work to the perceived quality of end-of-life care. It is however not possible to determine the causality (cf. satisfaction towards end-of-life care and table 3).
Distress in end-of-life care management during the current rotation
- Distress related to the perception of unreasonable obstinacy
Among residents who felt they were witnessing unreasonable obstinacy (n=313), 64.6% were hurt by the situation. This distress was associated with the feeling to be unable to express their disagreement on the course of treatment in 71.7% of cases. Distress was also increased when feeling that the end-of-life care was insufficient (cf table 4). Conversely, the perceived quality of supervision what associated with a lesser risk of distress.
- Repercussion on personal life
The need to care of dying patients in the context of their hospital rotation is associated with negative impact on their personal life for 67.2% (n=353) of the surveyed residents.
Among them, 55.4% felt that their professional work impacted their relationship with their close relatives; 50.4% felt they were more anxious after these end-of-life care; 21.5% had reliving phenomenon; 20.8% suffered from insomnia after these events. The details of these elements are in figure n°2 and table 5.
Residents having felt an interaction with their personal life are more prone to wish to avoid end-of-life care in the future (30.9% versus 17.4%; p=0,001).
The number of ways of interactions with personal life differs depending on the residents (cf. figure n°3)
The proportion of residents wishing to avoid being responsible for dying patients depends on the number of personal life’s settings previously touched by this situation (R2: 0.8247) (figure n°4)
Residents who feel their clinical duties impact their personal life often thought the end of life care of their patient was not sufficient. They also have more difficulties in their communications with their patients (details in table 5).
As expected, residents having felt an impact of end-of-life care on their personal life wished more for a systematic psychological support in at risk departments. (61.5% VS 45.3%; p=0.0004).
Table n°5: Clinical duties impact on residents’ personal life
Impact of difficulties met: desire to avoid caring for dying patients.
Factors associated with the desire not to care for any new dying patients were: the fear to shorten life with end-of-life care treatments (analgesic and anxiolytics) (p=0.0002), communication difficulties with the patient and its relatives (p = 5.32.10-6 and p=0.0004 respectively), impact on personal life (p=0.001).
Conversely, the quality of end-of-life care (p=1.21.10-5), residents’ supervision by seniors (p=0.0002), and desire to have an end-of-life care activity in the future (p=0.05) were factors associated with the absence of avoidance of end-of-life care patients. Details are in table n°6.
Potential interest of a psychological support for residents
Among residents who filled out the survey, 56.2% thought that a systematic psychologic support should be implemented in at risk departments to decrease the risk of extraprofessional impact of the care of severe patients. Departments that were considered at risk were oncology, hematology, critical care or geriatrics. Factors associated with the demand for a psychological follow up are: distress related to the perception of unreasonable obstinacy (p=0,028), interaction of those care with the resident’s personal life (p=0.00004), and the desire to avoid new end-of-life care (p=0.0007). Conversely residents who were satisfied with their supervision did not feel as strongly the need for a psychological support (p=0.005).