***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The lay caregiving role is integral to advanced cancer care but places carers ' health at risk . A supportive General Practitioner ( GP ) can help primary lay carers manage their health , if they disclose their concerns . A Needs Assessment Tool for Caregivers ( NAT-C ) was developed for carers to self-complete and use as the basis of a GP consultation , then tested in a r and omised controlled trial . This paper reports a qualitative research study to determine the usefulness and acceptability of the NAT-C in the Australian primary care setting . Convenience sample s of 11 carers and 5 GPs were interviewed between September 2010 and December 2011 regarding their experiences with and perceptions of the NAT-C.  Open-ended questions were used , and the transcripts were analysed qualitatively to identify themes and patterns . Three major themes were identified : ( a ) Acceptability of the intervention ; ( b ) Impact of the intervention on the GP-patient relationship ; and ( c ) Place of the intervention in advanced cancer care . This simple checklist was acceptable to carers , although some were uncertain about the legitimacy of discussing their own needs with their GP . Carer- patients could not be certain whether a GP would be willing or equipped to conduct a NAT-C-based consultation . Such consultations were acceptable to most GPs , although some already used a holistic approach while others preferred brief symptom-based consultations . Although the NAT-C was acceptable to most carers and GPs , supportive consultations take time . This raises organisational issues to be addressed so carers can seek and benefit from their GP 's support CONTEXT A clear underst and ing of what patients , families , and health care practitioners view as important at the end of life is integral to the success of improving care of dying patients . Empirical evidence defining such factors , however , is lacking . OBJECTIVE To determine the factors considered important at the end of life by patients , their families , physicians , and other care providers . DESIGN AND SETTING Cross-sectional , stratified r and om national survey conducted in March-August 1999 . PARTICIPANTS Seriously ill patients ( n = 340 ) , recently bereaved family ( n = 332 ) , physicians ( n = 361 ) , and other care providers ( nurses , social workers , chaplains , and hospice volunteers ; n = 429 ) . MAIN OUTCOME MEASURES Importance of 44 attributes of quality at the end of life ( 5-point scale ) and rankings of 9 major attributes , compared in the 4 groups . RESULTS Twenty-six items consistently were rated as being important ( > 70 % responding that item is important ) across all 4 groups , including pain and symptom management , preparation for death , achieving a sense of completion , decisions about treatment preferences , and being treated as a " whole person . " Eight items received strong importance ratings from patients but less from physicians ( P<.001 ) , including being mentally aware , having funeral arrangements planned , not being a burden , helping others , and coming to peace with God . Ten items had broad variation within as well as among the 4 groups , including decisions about life-sustaining treatments , dying at home , and talking about the meaning of death . Participants ranked freedom from pain most important and dying at home least important among 9 major attributes . CONCLUSIONS Although pain and symptom management , communication with one 's physician , preparation for death , and the opportunity to achieve a sense of completion are important to most , other factors important to quality at the end of life differ by role and by individual . Efforts to evaluate and improve patients ' and families ' experiences at the end of life must account for diverse perceptions of quality . JAMA . 2000;284:2476 - 2482 Background Due to a rising number of deaths from cancer and other chronic diseases a growing number of people experience complex symptoms and require palliative care towards the end of life . However , population -based data on the number of people receiving palliative care  in Europe are scarce . The objective of this study is to examine , in four European countries , the number of people receiving palliative care in the last three months of life and the factors associated with receiving palliative care . Methods Cross-national retrospective study . Over two years ( 2009–2010 ) , GPs belonging to representative epidemiological surveillance networks in Belgium , the Netherl and s , Italy , and Spain registered weekly all deaths of patients ( ≥18 years ) in their practice s and the care they received in the last three months of life using a st and ardized form . Sudden deaths were excluded . Results We studied 4,466 deaths . GPs perceived to have delivered palliative care to 50 % of patients in Belgium , 55 % in Italy , 62 % in the Netherl and s , and 65 % in Spain ( p<.001 ) . Palliative care specialists attended to 29 % of patients in the Netherl and s , 39 % in Italy , 45 % in Spain , and 47 % in Belgium ( p<.001 ) . Specialist palliative care lasted a median ( inter-quartile range ) of 15 ( 23 ) days in Belgium to 30 ( 70 ) days in Italy ( p<.001 ) . Cancer patients were more likely than non-cancer patients to receive palliative care in all countries as were younger patients in Italy and Spain with regard to specialist palliative care . Conclusions Although palliative care is established in the countries studied , there are considerable differences in its provision . Two potentially underserved groups emerge non-cancer patients in all countries and older people in Italy and Spain . Future research should examine how differences in palliative care use relate to both patient characteristics and existing national health care policies OBJECTIVE Despite being ideally placed to provide care to patients with terminal illness , many general practitioners ( GPs ) are not involved in palliative care . This study aim ed to determine the level of participation of Australian urban GPs in palliative care , and to determine the main barriers facing them in providing this care . DESIGN Cross-sectional postal survey . PARTICIPANTS AND SETTING Between March and May 2007 a r and om sample of 500 GPs from southwestern and northern regions of Sydney were surveyed . MAIN OUTCOME MEASURES  Involvement in palliative care ;  personal and professional characteristics of the GPs related to the provision of palliative care ; GPs ' views on barriers to their involvement in palliative care ; GPs ' confidence levels across different issues in palliative medicine . RESULTS Response rate was 61 % and of these 25 % of GPs were not involved in palliative care . GPs not providing palliative care were more likely to be younger , have less GP experience , work less hours , be an employee rather than a practice owner , and educated overseas . Main barriers to GPs ' involvement in palliative care were lack of interest and knowledge , home visits , problems with after-hours care due to family and personal commitments . GPs felt least confident about psychosocial problems and technical aspects of palliative medicine . CONCLUSION About one quarter of GPs surveyed are not involved in palliative care . Strategies to increase GPs ' involvement should aim at increasing their knowledge and interest in palliative care . Innovations in service provider models are required to overcome the barriers to provision of after-hours care Objective To investigate the impact of advance care planning on end of life care in elderly patients . Design Prospect i ve r and omised controlled trial . Setting Single centre study in a university hospital in Melbourne , Australia . Participants 309 legally competent medical in patients aged 80 or more and followed for six months or until death . Interventions Participants were r and omised to receive usual care or usual care plus facilitated advance care planning . Advance care planning aim ed to assist patients to reflect on their goals , values , and beliefs ; to consider future medical treatment preferences ; to appoint a surrogate ; and to document their wishes . Main outcome measures The primary outcome was whether a patient ’s end of life wishes were known and respected . Other outcomes included patient and family satisfaction with hospital stay and levels of stress , anxiety , and depression in relatives of patients who died . Results 154 of the 309 patients were r and omised to advance care planning  , 125 ( 81 % ) received advance care planning , and 108 ( 84 % ) expressed wishes or appointed a surrogate , or both . Of the 56 patients who died by six months , end of life wishes were much more likely to be known and followed in the intervention group ( 25/29 , 86 % ) compared with the control group ( 8/27 , 30 % ; P<0.001 ) . In the intervention group , family members of patients who died had significantly less stress ( intervention 5 , control 15 ; P<0.001 ) , anxiety ( intervention 0 , control 3 ; P=0.02 ) , and depression ( intervention 0 , control 5 ; P=0.002 ) than those of the control patients . Patient and family satisfaction was higher in the intervention group . Conclusions Advance care planning improves end of life care and patient and family satisfaction and reduces stress , anxiety , and depression in surviving relatives . Trial registration Australian New Zeal and clinical trials registry ACTRN12608000539336 BACKGROUND : Discussion s of end-of-life care should be held prior to acute , disabling events . Many barriers to having such discussion s during primary care exist . These barriers include time constraints , communication difficulties , and perhaps physicians ’ anxiety that patients might react negatively to such discussion s. OBJECTIVE : To assess the impact of discussion s of advance directives on patients ’ satisfaction with their primary care physicians and outpatient visits . DESIGN : Prospect i ve cohort study of patients enrolled in a r and omized , controlled trial of the use of computers to remind primary care physicians to discuss advance directives with their elderly , chronically ill patients . SETTING : Academic primary care general internal medicine practice affiliated with an urban teaching hospital . PARTICIPANTS : Six hundred eighty-six patients who were at least 75 years old , or at least 50 years old with serious underlying disease , and their 87 primary care physicians ( 57 residents , 30 faculty general internists ) participated in the study . MEASUREMENTS AND MAIN RESULTS : We assessed patients ’ satisfaction with their primary care physicians and visits via interviews held in the waiting room after completed visits . Controlling for satisfaction at enrollment and physician , patient , and visit factors , discussing advance directives was associated with greater satisfaction with the physician ( P=.052 ) . At follow-up , the strongest predictor of satisfaction with the primary care visit was having previously discussed advance directives with that physician ( P=.004 ) , with a trend toward greater visit satisfaction when discussion s were held during that visit ( P=.069 ) . The percentage of patients scoring a visit as “ excellent ” increased from 34 % for visits prior without advance directive discussion s to 51 % for visits with such discussion s ( P=.003 ) . CONCLUSIONS : Elderly patients with chronic illnesses were more satisfied with their primary care physicians and outpatient visits when advanced directives were discussed . The improvement in visit satisfaction was substantial and persistent . This should encourage physicians to initiate such discussion s to overcome communication barriers that might result in reduced patient satisfaction levels OBJECTIVE Late or non-referral of patients to specialist palliative care ( SPC ) services may affect patients ' and their carers ' quality of care . General practitioners ( GPs ) are key professionals in linking people with SPC . The aim of this article is to assess GPs ' perceptions and SPC referrals for their patients with advanced cancer and differences between metropolitan ( M GPs ) and non-metropolitan GPs ( NM GPs ) . METHOD Self-report survey mailed to a stratified r and om sample of 1,680 Australian GPs was used . RESULTS Thirty-one percent ( 469 ) of eligible GPs returned surveys . More M GPs than NM GPs reported referring > 60 % of their patients for SPC ( p = 0.014 ) ; and that a more comprehensive range of SPC services was available . The most frequently reported referral prompts were : presence of terminal illness ( M GPs , 71 % , NM GPs , 66 % , ns ( not significant ) ) ; future need for symptom control ( 69 % vs. 59 % , ns ) and uncontrolled physical symptoms ( 63 % vs. 54 % , ns ) . Reasons for not referring were : doctor 's ability to manage symptoms ( 62 % vs. 68 % , ns ) and the absence of symptoms ( 29 % vs. 18 % , p = 0.025 ) . Higher referral was associated with : having a palliative care physician or consultative service available ; agreeing that all patients with advanced cancer should be referred , and agreeing that with SPC , the needs of the family are better met . SIGNIFICANCE OF RESULTS Referrals for SPC were primarily disease-related rather than for psychological and emotional concerns . Measures are needed to encourage referrals based upon psychosocial needs as well as for physical concerns , and to support GPs caring for people with advanced cancer in areas with fewer comprehensive SPC services We surveyed primary care physicians about their involvement and perceived skills in palliative care .  A survey instrument asked how frequently internal medicine and family practice physicians performed 10 palliative care items . Subjects rated their skills in each area . A majority of physicians always or frequently performed all 10 palliative care items , but fewer than 50 % of respondents adequately attended to the spiritual needs and economic problems of patients . Interest in palliative care was associated with an increased frequency in performing palliative care items ( P = 0.036 ) , while training in palliative care was associated with better perceived performance ( P = 0.05 ) . Only 36 % of respondents had received training in palliative care . Internists and family practitioners provide palliative care to patients , but feel their skills are lacking in certain areas . Training may improve care to patients at the end of life The objectives of this study were to establish the extent to which UK primary care has adopted recommended practice s on supportive and palliative care of adults with cancer , and to relate this to participation in national initiatives . We conducted a cross-sectional postal question naire survey of a r 
    Output:
    
Patients and carers expect their GPs to be competent in all aspects of palliative care .
They valued easy access to their GP , a multidisciplinary approach to care and well-coordinated and informed care .
They also wanted their care team to communicate openly , honestly and empathically , particularly as the patient deteriorated .
ACP and the involvement of GPs were important factors which contributed to patients being cared for and dying in their preferred place .
Patients and carers prefer a holistic approach to care .
This review shows that GPs have an important role in ACP and that their involvement facilitates dying in the place of preference .