***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: BACKGROUND General practitioners ( GPs ) have a central role in palliative care , yet research continues to reveal room for improvement in symptom control at home . There is a need to evaluate how well-prepared GPs are for this task of caring for the dying at home . AIM To evaluate the training in palliative care GPs have received throughout their careers . METHOD Postal survey of 450 r and omly selected East Anglian GP principals , investigating training in five areas of palliative care ( pain control , control of other symptoms , communication skills , bereavement care , use of syringe driver )  , as clinical students , junior hospital doctors , GP trainees ( registrars ) , and GP principals . RESULTS A response rate of 86.7 % was obtained . While GPs were clinical students , training was uncommon , ( 32 % reported no training in pain control , and 58 % no training in bereavement care ) , although there has been a significant increase in more recent years . Training as junior doctors was particularly uncommon ( over 70 % report no training in communication skills or bereavement care ) ; there was some evidence of an increase in more recent years . During the GP trainee year , training was much more common . For GP principals , most areas had been covered , although over 20 % reported no training in communication skills and bereavement care . During the community-based years as trainee and principal , training was significantly more common than during the hospital-based years of training as clinical student and junior doctor . CONCLUSIONS There is a continuing need for medical education in palliative care . Particular attention should be paid to the basic medical education of clinical students and the training of junior doctors , especially regarding communication skills and bereavement care Abstract Objective : To evaluate a palliative care home support team based on an inpatient unit . Design : R and omised controlled trial with waiting list . Patients in the study group received the service immediately , those in the control group received it after one month . Main comparison point was at one month . Setting - A city of 300 000 people with a publicly funded home care service and about 200 general practitioners , most of whom provide home care . Main outcome measures : Pain and nausea levels were measured at entry to trial and at one month , as were quality of life for patients and care givers ' health . Results : Because of early deaths , problems with recruitment , and a low compliance rate for completion of question naires , the required sample size was not attained . Conclusion : In design ing evaluations of palliative care services , investigators should be prepared to deal with the following issues : attrition due to early death , opposition to r and omisation by patients and referral sources , ethical problems raised by r and omisation of dying patients , the appropriate timing of comparison points , and difficulties of collecting data from sick or exhausted patients and care givers . Investigators may choose to evaluate a service from various perspectives using different methods : controlled trials , qualitative studies , surveys , and audits . R and omised trials may prove to be impracticable for evaluation of palliative care The views of family doctors on local specialist palliative care services such as hospices and home care teams and the needs of their patients were studied . Of 203 family doctors sent a question naire , 102 ( 50 % ) responded . Attempts were made to follow up a r and om sample of 42 non-responders by telephone interview . During the previous two years family doctors had referred a mean of 5.5 patients to inpatient specialist palliative care services . A further 4.7 patients had been referred to specialist palliative home care teams . During the same two years family doctors had cared for a mean of 2 patients during the terminal phase of illness without input from specialist palliative care services . Although many reports about the services were favorable , family doctors wished for improved communication and liaison from palliative care services , input for patients who did not have cancer , and improved out-of-hours access . The telephone survey of non-responders suggested that these doctors had lower levels of awareness of palliative care problems and services . The findings support the move by specialist palliative care services to extend their remit beyond cancer and to provide 24-hour care . They also signal a need for caution if primary care is to determine the development of palliative care BACKGROUND Previous studies have demonstrated deficiencies in palliative care in the community . One method of translating the results of research into clinical practice , in order to produce more effective health care , is the development of clinical guidelines . Setting st and ards for such care has been performed by care teams in both hospital and hospice setting s but not in primary care . AIM This study set out to develop guidelines for primary care teams to follow in the provision of palliative care in the community using facilitated case discussion s with the members of such teams , as a form of internal audit . METHOD Five practice s were r and omly chosen from the family health services authority medical list . Meetings between the facilitators and primary care teams were held over a period of one year . The teams were asked to describe good aspects of care , areas of concern and suggestions to improve these , in recent cases of patient deaths . RESULTS In total 56 cases were discussed . All practice s felt that cohesive teamwork , coordinated management , early involvement of nursing staff and the identification of a key worker were essential for good terminal care . Concerns arose in clinical and administrative areas but the majority were linked to poor communication , either between patient and professionals within the primary care team or between primary and secondary care . All the positive aspects of care , concerns and suggestions were collated by the facilitators into guidelines for teams to refer to from the initial diagnosis of a terminal illness through to the patient 's death and care of the relatives afterwards . CONCLUSION Developing multidisciplinary as opposed to medical guidelines for palliative care allows primary health care teams to create st and ards that are acceptable to them and stimulates individuals within the teams to accept responsibility for initiating the change necessary for more effective care . The process of facilitating teams to discuss their work allows for recognition and respect of individuals ' roles and more importantly provides shared ownership , an important contributory factor in the implementation of guidelines A two year follow-up of two matched groups of subjects with chronic severe mental illness was performed in order to evaluate a new  psychiatric case management system .  One group ( n=59 ) received care through psychiatric case management , using an assertive community treatment model that directly involved general practitioners . The other group , matched for age , sex , diagnostic group and number of hospital admissions , received st and ard outpatient care . Comparing the two years before and after case management , the experimental group showed a dramatic fall in inpatient admission days while the control group admission days remained the same ( median difference in admission days across matched subject pairs = 64.5 , 95 % C.I. from 134.5 to 16 ) . The experimental group remained out of hospital longer before first readmission ( Kaplan-Meier survival analysis , P=0.002 ) . This type of case management programme can shorten or prevent admissions to psychiatric hospitals of patients with chronic mental illness , and increase their time before readmission BACKGROUND Cancer patients may unnecessarily suffer from pain and other symptoms due to insufficient knowledge on the part of their doctors . In The Netherl and s , the general practitioner is considered to be the key provider of palliative care for the cancer patient . Therefore , the authors developed and conducted workshops to teach symptom control to general practitioners . These workshops contained learning objectives from which they selected 18 items to form a question naire with five-point response scales . The goal of this study was to investigate changes in the knowledge and attitude scores of the participating general practitioners . METHODS The participants were asked to complete the question naire at the start of the workshop and also four months later . RESULTS Responses were obtained from 120 general practitioners for the pre-workshop and 96 for the post-workshop question naires . The majority of the scores increased toward the desired effect , and some items ' scores improved by almost two points . CONCLUSION The results suggest improvements in general practitioners ' knowledge and attitude scores with regard to cancer pain and symptom management . Future studies should try to link these improvements with quality -of-life parameters of terminal cancer patients and their families BACKGROUND The objective of this study is to evaluate whether a single palliative cancer care workshop , which included information about drug prescribing , had an effect on the opioid-prescription patterns of general practitioners in daily practice . METHOD The opioid-prescription figures of 68 general practitioners who had participated in the workshop were aggregated from the computer system of the Regional Sick Fund . The prescription figures of a year before and a year after the workshop were compared and a control group of non- participants was included . RESULTS This study showed a limited efficacy of a palliative cancer care workshop on the morphine-prescription figures of the general practitioners in daily practice . This limited effect did not accord with the results of a pre- and post-workshop question naire evaluating the attitudes of the same practitioners . CONCLUSION A single workshop can not effectuate substantial changes in prescription behaviors . Possibilities for more reinforcements are discussed The general practitioners , hospital consultants and community nurses who had cared for a r and om sample of people who died were asked about their relationships with the other professional groups and for their views and experiences of specialist domiciliary terminal care services . Many of the general practitioners and the nurses were critical of hospital communication over discharge . The most frequent criticism made by community nurses of general practitioners was that they did not ask for nursing help early enough for people who were dying . This may be because many general practitioners regarded the community nursing services as overstretched . General practitioners were rather less enthusiastic than the other two professional groups about specialist medical or nursing domiciliary terminal care services . They were , however , more convinced of the helpfulness of these services if they had some experience of them OBJECTIVE We aim ed to assess whether GP input into discharge planning for high-risk aged in- patients admitted under the care of a geriatrician results in improved patient outcomes . METHODS We conducted a prospect i ve r and omized controlled trial in Sydney , Australia . The subjects were 364 patients aged 60 years and over . The main outcome measures included community service referral , accommodation changes , length of stay , readmission rate , length of time to first readmission and patient satisfaction with discharge arrangements . RESULTS No significant differences were found with regard to length of stay , readmission rates or time to first readmission . Test-group subjects were significantly more likely to be recommended for community services at discharge and to report that hospital personnel had discussed their discharge plan with them . Significantly more of the test group reported that their return home was well prepared . CONCLUSIONS Although GP pre-discharge visits did not alter the likelihood of ' hard outcomes such as risk of readmission ' , the results suggest that quality of care is enhanced amongst patients receiving a pre-discharge visit and that GPs can perform a key role in planning post-discharge care with other services Inadequate physician knowledge , particularly in areas of pain assessment and use of analgesics , has been identified as a major factor contributing to poor pain management in cancer patients . In most medical schools , teaching in Palliative Care at both the undergraduate and postgraduate levels is limited or nonexistent . Baseline knowledge and changes in knowledge in areas relevant to Palliative Care were assessed by the use of 2 16- question examinations ( Exams A and B ) in 78 second-year Family Medicine Residents from the University of Alberta Family Medicine Residency Program . The residents participated in a two-week rotation on the Acute Palliative Care Unit at the Edmonton General Hospital or Grey Nuns Community Health Centre between September 1991 and February 1996 . The residents were r and omly assigned on their first day ( Time 1 ) to complete either Exam A or B and were subsequently crossed over on their final day of the rotation to complete the alternate Exam ( Time 2 ) . Six domains were represented in the Exams as follows : pain assessment , opioid use , adjuvant medications , delirium , urinary catheterization , and hydration . Improvements were noted in the mean percentage results in Time 2 compared with Time 1 for Exams A , B , and A and B combined . Mean global percentage results were 53 + /- 15 versus 73 + /- 13 ( p < 0.001 ) at Times 1 and 2 , respectively . There were significant improvements for domains in Time 2 compared to Time 1 ( p < or = 0.05 ) for combined A and B Exam except for urinary catheterization . Despite these documented improvements in scores , serious deficiencies were identified particularly in the areas of pain assessment and opioid use , namely opioid sude effects and issues involving dependence , addiction , and tolerance . Examinations , such as the two used in this study , can be a useful aid in assessing physician knowledge in addition to structuring teaching in Palliative Care . Examination content will require updating as knowledge in Palliative Care evolves Abstract Objective : To evaluate the impact on place of death of a hospital at home service for palliative care . Design : Pragmatic r and omised controlled trial . Setting : Former Cambridge health district . Participants : 229 patients referred to the hospital at home service ; 43 r and omised to control group ( st and ard care ) , 186 r and omised to hospital at home .  Intervention : Hospital at home versus st and ard care . Main outcome measures : Place of death . Results : Twenty five ( 58 % ) control patients died at home compared with 124 ( 67 % ) patients allocated to hospital at home . This difference was not significant ; intention to treat analysis did not show that hospital at home increased the number of deathsat home . Seventy three patients r and omised to hospital at home were not admitted to the service . Patients admitted to hospital at home were significantly more likely to die at home ( 88/113 ; 78 % ) than control patients . It is not possible to determine whether this was due to hospital at home itself or other characteristics of the patients admitted to the service . The study attained less statistical power than initially planned . Conclusion : In a locality with good provision of st and ard community carewe could not show that hospital at home allowed more patients to die at home , although neither does the study refute this . Problems relating to recruitment , attrition , and the vulnerability of the patient group make r and omised controlled trials in palliative care difficult . Whilethese difficulties have to be recognised they are not insur 
    Output:
    
However , reports from bereaved relatives suggest that palliative care is performed less well in the community than in other setting s. GPs express discomfort about their competence to perform palliative care adequately .
They tend to miss symptoms which are not treatable by them , or which are less common .
However , with appropriate specialist support and facilities , GPs have been shown to deliver sound and effective care .
GP comfort working with specialist teams increases with exposure to this form of patient management , as does the underst and ing of the potential other team members have in contributing to the care of the patient .
Formal arrangements engaging GPs to work with specialist teams have been shown to improve functional outcomes , patient satisfaction , improve effective use of re sources and improve effective physician behaviour in other areas of medicine .