Family physicians’ continuity of care pivotal in depressed terminally ill patients

By Sarah Guy

The long-standing relationship between a family physician and his/her terminally ill patient is pivotal in the management of depression during palliative care, show Dutch study results.

While physicians frequently observed depressive symptoms in their palliative care patients and felt generally competent to deal with them, they highlighted difficulties distinguishing depression from normal sadness.

"The moment I think a person with cancer in this phase is depressed, then it [the behavior] has to differ from the pattern you expect there to be," said one doctor, who added that as a family physician, he knows how a patient would normally react and can use this as a marker of whether they are depressed.

Furthermore, the majority of physicians were hesitant in diagnosing a depressive disorder in palliative patients, with one study participant remarking that he did not want to interfere with the normal patient adaptation process.

"A disadvantage of a conservative approach to diagnosing depression might be that depressed palliative care patients do not receive optimal treatment," say researcher Franca Warmenhoven (Radboud University Nijmegen Medical Centre, the Netherlands) and colleagues.

"However, if the supportive and contextual care that family physicians offer is adequate for most patients, it might spare many patients unnecessary intensive and sometimes harmful treatment," they add, in the Annals of Family Medicine.

A total of 22 Dutch family physicians took part in the study, forming four focus groups that met to discuss the recognition, diagnosis, and management of depression in palliative care patients.

Physicians were comfortable in open conversation with patients and/or their caregivers and partners (where appropriate) that explored the nature of depressive feelings, and felt happier relying on "gut feelings" rather than clinical screening instruments.

Few physicians, and indeed only those with a greater expertise in palliative care, reported prescribing antidepressants or stimulants. Those who did emphasized the importance of intensive psychologic support, and always used pharmacotherapy in combination with such support, note Warmenhoven et al.

One physician hesitated from using pharmacotherapy because he did not want to "interfere in the process of accepting the end of life."

To remedy some of the difficulties encountered, the physicians indicated they would like more education or support from a guideline on how to identify depression in palliative patients.

Guidelines will be valuable only in the context of a person-centered approach, however, since such an approach acknowledges the importance of cumulative and contextual knowledge, "which is a core quality of family practice," conclude Warmenhoven and co-authors.

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