Palliative care among general practitioners: why this blockage?

On April 1, 2023, general practitioner Roland Fardel judged, in a column in the World, that the lack of dissemination of palliative culture in France was “essentially attributable to the resistance of caregivers”. These would be too focused on curative, treating the cause, and not enough on palliative – treating the symptoms of pain while taking into account psychological, social and spiritual suffering.

What do general practitioners, who are on the front line of palliative care, think? Most are more nuanced, like Arnaud Garreau, general practitioner at the Western Cancer Institute (ICO) in Angers: “The two obstacles are lack of time and loneliness. The general practitioner often works 60 hours per week. He has the right to have a life, he cannot go home all the time. And he often remains alone in his practice, one-on-one with the patient. » Trained in palliative care and a former country doctor, Arnaud Garreau knows that quality palliative care requires several caregivers. Because we form a more detailed diagnosis together, because they can take over from each other when a caregiver weakens.

Chantal Prat, a retired general practitioner in Saint-Denis (Seine-Saint-Denis), has been the attending physician for families over four, sometimes five generations. With the help of ties, she naturally followed many of them until their death: “We cannot abandon them in the most difficult times. » She was able to do this because a palliative care network had been set up in her town. “Without him, I would have done it a lot worse. Palliative care is the epitome of care that cannot be done alone. » The caregivers informed her about the side effects of each chemotherapy – not all have the same effects. Some took care of the administrative part, such as ordering patient lifts or morphine pumps for home care. Has she ever pulled the rope? ” Without a doubt. But the network also serves to relieve us of guilt sometimes when we fear having supported the person badly, to support ourselves. It's very intense. »

Vladimir Druel, general practitioner in Deyme (Haute-Garonne) and palliative care coordinator in Gers for ten years, has only met one general practitioner reluctant to palliative care. This doctor refused to prescribe morphine to a patient because he believed that morphine should only be prescribed to a patient at the end of life. However, palliative care is not just reserved for the dying. “The end of life is only a very small part of palliative care,” he recalls. The amalgamation still exists.

The main obstacle remains the lack of resources, for Vladimir Druel. “I stopped palliative care in the Gers because my new management only offered me video consultations or telephone interviews. For me, you cannot explain sedation to a patient in tears via video conference. Morally, this cannot be done. You must be physically present. » Likewise, it was inconceivable for him that deep sedation of a patient would only be accomplished by a nurse at home, while the doctor ensured a presence by telephone, as he has already seen. “It takes two,” he says. It's a heavy operation. It's not nothing to put someone to sleep who may never wake up again. You need someone to monitor the machine and someone to reassure the family. »

The palliative care network in Saint-Denis mentioned by Chantal Prat was set up during the explosion of the AIDS epidemic. But the lack of personnel weakens it. “We have been trying to recruit doctors for this network for four years. We don't find any. The organization is broken by the lack of personnel,” regrets Chantal.

Jean-Marie Commer, doctor at the ICO, notes another obstacle: palliative care at home requires more vigilance and energy from the general practitioner than in the hospital. “An old doctor once told me that city patients are wild, those in the hospital are domestic. Because it is easier to get the patient to adhere to treatment in hospital. Some, at home, end up stopping their treatment. Or lie about their care. Which causes us to make false diagnoses. The person at home needs a lot, a lot of support. » He concedes, however, that palliative care at home is infinitely preferable to hospital care. “It’s a gift, to be cared for at home. It's much quieter than a hospital – the trolleys passing over the expansion joints in the corridors make a racket… It's also warmer and more accessible to loved ones – there is no visiting hours. But that requires resources. »