Family physicians play a vital role in helping terminally ill patients to die in comfortable and familiar surroundings, according to new findings published in the Annals of Family Medicine.

Researchers, led by Thijs Reyniers, from Vrije Universiteit Brussel in Belgium, sought to better understand family physicians’ perceptions regarding their roles and the difficulties faced caring for the seriously ill. Discussions with 39 family physicians, also known as primary care doctors, from across Belgium were transcribed and analyzed.

Five pivotal roles of family physicians were identified: care planner, anticipating future scenarios; initiator of decisions in acute situations, mostly in an advisory manner; provider of end of life care, in which competency and attitude is considered important; provider of support, being available during acute situations; and as a decision maker, taking overall responsibility. In Belgium there is a strong emphasis on primary care, with almost 95 percent of the population having a family physician whom they consult regularly.

Despite end of life care policies in Belgium aiming to help make home death more common and easier, the acute hospital setting remains the most common place for final care and death (52 percent). In comparison, 36 percent of U.S. patients die in hospitals, down from 49 percent in 1989. But the use of aggressive end of life care and hospital services has been steadily increasing in both countries in recent years.

“In an elderly population in the United States, intensive care unit use in the last month of life has been shown to have increased from 24 percent to 29 percent between 2000 and 2009. Moreover, in Belgium, as in other countries, the hospitalization rates of patients who died after a gradual decline have been found to increase exponentially in the last months of life,” researchers write.

In the U.S. and most European countries, the vast majority of patients say they wish to die at home, but most do not. Researchers suggest family physicians could help make home death more common and hope the study– being billed as the first to use a focus group methodology to explore the experiences of family physicians– will encourage more doctor-patient communication. Home or nursing home death is more likely when the family physician makes frequent visits to the patient in the last three months before death.

“Family physicians face many different and complex roles and difficulties in preventing and guiding hospital admissions at the end of life,” researchers add. “Enhancing the family physician’s role as a gatekeeper to hospital services, offering the physicians more end of life care training, and developing or expanding initiatives to support them could contribute to a lower proportion of hospital admissions at the end of life.”

One unnamed participant said a doctor’s attitude can determine whether-or-not a patient receives a late hospitalization:

What is avoidable for one colleague is not necessarily avoidable for another… I think it also has to do with the doctor’s own attitude. How you think about these things as a person… If you are convinced that you have to try and save the patient’s life in every case and at all cost, with all possible means, the patient will sooner be admitted to the hospital.

Being supported by a local palliative care services specialist was considered important and helpful to another doctor:

Therefore I also found it important to work with a palliative home team for once, to give you some breathing space… I think that it also benefits the family physician’s strength when you work with these people.