Our work has pointed out that GP residents having finished at least one rotation in a hospital ward have many difficulties regarding the end-of-life care. The first obstacle standing is the implementation of comfort care itself because of a lack of mastery in the use of pain and anxiety medicine in the specific context of end-of-life care. The difficulty they have in communicating about death also plays an important role in the trauma felt by our population. Also, the feeling of giving insufficient care because of those difficulties has a negative impact on the residents’ personal life. All of these factors lead the most affected residents to avoid future contact with palliative care.
End of life care is an important part of medical training. Although family medicine is usually about caring for patients with less severe pathology, family doctors often have to care for patients wishing to die at home [21]. A specific training during medical school has been implemented and strengthened in the last decades, but our results underline the persistent difficulties met by physicians. Our study blends in the current work about young physicians’ preoccupations regarding end-of-life care [9], even though the population is younger and working in a different place than the one they are training to work in the future. Despite those differences, results are similar [9], which underlines that difficulties in apprehending end-of-life care depends very little on the professional orientation of young physicians.
The quality of end-of-life care is the main preoccupation of GP residents. Imperfections experienced by our population were associated with a lack of ease of sedatives and anxiolytic treatments use as well as communicating with the patient and their relatives. Such feeling of unpreparedness toward those situations has been widely reported and may concern as far as 80% of young physicians [22]. The lack of theoretical training, in particular regarding pharmacological end of life care therapeutics, is often reported [22,23,24,25,26,27]. Some work from the beginning of the year 2000 pointed out this lack of training amongst general practitioners [28]. Although the medical training has been widely modified since, it seems to still be true.
Patients with fatal disease often ask for the possibility to discuss end of life care with their physician [29]. However, young physicians [9, 30, 31] as well as residents [30] are faced with difficulties in communicating in this situation. In the same fashion, residents find it difficult to determine the right time for implementing palliative care as well as the practical management of patients’ complaints. These difficulties have also been reported by internal medicine residents [23] who are more used to these end-of-life care situations, including during their critical care rotations [24].
Relations with relatives may need particular attention. Indeed, the severity of the illness or disagreements, regarding the orientation and intensity of care, may be cause for tensions between relatives and physicians and might be difficult to accept in the particular context of end of life care [32]. Also, satisfaction of grieving families depends on the quality of medical attention both in end of life care decisions and organization as well as in the post death support [33].
Lack of practice seems to be the main cause for communication difficulties. The absence of specific training in end of life communication is associated with physician discomfort and unease feelings [34,35,36]. Consequently, it is also a risk factor for burn-out [15]. Bedside training is often offered, but associated with a poor psychological tolerance [27]. High fidelity scenarios as well as seminars, while confronting residents to pragmatic situation without the psychological burden, might improve residents’ future competence [23, 37]. Distance training has also proven to be efficient to improve young physicians’ communication skills [31]. This improvement of end of life care management’s skills is associated with a diminution of anxiety in these situations [38]. Conversely, lack of trust in ones skills and communication, in particular in breaking bad news, are at the center of health care worker’s psychological distress [12, 15].
In our work, all of these elements are associated with a psychological burden on more than two third of replying GP residents. Similar results were obtained in different populations of young and inexperienced physicians, also leading to psychological distress, similar to post-traumatic disorders [9]. Patient’s loss may lead to psychological distress because of a sense of guilt, or even burn-out. [39]. This distress is mostly due to death events [40, 41] and uncertainty around end-of-life care [38]. Death is often accountable for guilt feelings and sometimes even sense of failure in physicians populations [27]. However, most of the publications about the effects of end-of-life care or care in severe situations are looking at experienced physicians in specialized departments [15].
As expected, supervision plays an import role in GP residents’ mental health and satisfaction during end-of-life care [26, 42, 43]. Lack of involvement, management and discussions lead to a situation of discomfort when faced to end-of-life care [26, 44]. In our work, help from senior physicians is associated with perceived good quality of care by the resident and with a lower risk of personal burden related to end-of-life care. This confirms previous observations in different populations [40]. Senior management remains, however, sometimes insufficient for young physicians [25, 26, 44, 45].
Supervision and adequate management medication use at end-of-life and decision-making process, must, however, not lead to the exclusion of residents during this care. Their exclusion could alter their training during residency [26] as experience depends on seniors ‘observation [46].
On a broader perspective, training is essential to prevent psychological consequences of medical activities. The quality of end-of-care training is correlated to patient’s end of life quality [47].
Our work has some limitations. Since the survey was filled out on a voluntary basis, the answers are not reflecting the mind of all residents. However, since the survey was offered to all residents orally, the absence of answer was not due to a lack of solicitation. Absence of participation was always due to participation’s refusal. Observed results confirm that participants were the most interested in end-of-life care (18% of replier wish to keep an end-of-life care activity in the future). Although they wish to care for end-of-life patients, perception of a lack of skills and psychological burden of this care on personal life are often reported, thus confirming their importance. Also, we only surveyed “Île-de-France” residents rather than all French residents. Residents from “Île-de-France” however represent almost a third of all French residents and are from all regions of France which allows an important representativeness of all residents. Finally, since answers were declarative, we cannot have any certainty about the reality of difficulties met and psychological impact. However, this limitation is common in this kind of work and links between psychological distress and perceived difficulties have been previously reported in similar situations with different physicians’ populations.
Our work allows a broad evaluation of the difficulties and consequences met by GP residents when they have to care for end-of-life patients in hospital settings. It also underlines the necessity to continue and strengthen their management during their hospital rotations.
