Patients, families, and College registrants have benefited enormously from the evolution and deployment of expertise in the care of patients at the end of life. In most BC communities, physicians, nurses, and others with a passion for this work now provide much of the care. When registrants meet with College staff, they invariably express appreciation for the palliative care services available to their patients. But human resources for palliative care teams across agencies and regions will vary over time. Gaps are inevitable. When they arise, other registrants must step up.
In the course of investigating complaints and fielding calls from registrants and the public, the College has noted two kinds of recurring scenarios:
- Near the end of life, a nurse, pharmacist, or family member contacts a physician seeking renewal of an analgesic or other medication in circumstances where a palliative care physician is not available or a member of a palliative care team (nurse or pharmacist) wishes to discuss a patient care issue with their family physician.
- At an earlier stage, a consultative service seeks to discharge a stable patient back to primary care, including ongoing prescribing.
In such circumstances, registrants are expected to be prompt and accommodating in their responses. Ensuring that symptoms are effectively palliated is one of the most urgent obligations in medical practice, and, potentially, among the most gratifying. The College acknowledges that these calls may be disruptive. But, thanks to the quality of palliative services generally, they are infrequent. The caller is invariably in need of assistance that only the registrant can realistically provide.
Most registrants manage these situations very well. Those who fall short may have failed to return a call; directly (or, worse, indirectly through staff) declined to assist; or inappropriately invoked the College standard Safe Prescribing of Opioids and Sedatives, which explicitly excludes cancer and palliative care.
Registrants working in walk-in settings are reminded that patients who attend repeatedly and consistently are considered to be attached at that location, and they should be familiar with other principles outlined in the College standard Primary Care Provision in Walk-in, Urgent Care, and Multi-physician Clinics. Longitudinal primary care for such patients is a collective responsibility shared by all registrants working there. When the call comes in, a registrant must field it.
Registrants engaged in primary care, whether in a traditional relationship-based practice or a walk-in clinic, must be prepared to accept patients discharged from specialist services and assume responsibility for prescribing (reference: Referral-Consultation Process). Registrants must not refuse a patient because they are on long-term opioid therapy. That would be discrimination. Decisions to change ongoing therapy must be based on well-documented, comprehensive assessments, as described in an article in the College Connector, Volume 5 | No. 3 | May/June 2017: Patients with chronic pain need family physicians—it’s unprofessional to turn them away.
Registrants who believe that they have been unfairly treated by another College registrant or health professional should ensure that the patient and family are insulated from any dispute and provide the requested service without delay (most often a bridging prescription or an urgent consultation). If they wish, they can also access advice by contacting the College or the CMPA.