Exploring how Japanese family physicians understand palliative care and identify patients for primary palliative care
Background: Primary care clinicians have great potential to play a key role in providing palliative care in the community. However, difficulties in identifying patients for palliative care hinders progress. This problem is particularly relevant in Japan with an elderly population where more complex and increasing amounts of palliative care needs are emerging. Aims: This study aimed to explore: 1) how Japanese family physicians understand the concepts of palliative care; 2) their current approaches to the identification of patients for palliative care; and 3) their perceptions and engagement with an international tool for identifying patients for palliative care translated into Japanese: the Supportive and Palliative Care Indicators Tool (SPICT). Design: Phase I: The SPICT was translated from English into Japanese following international guidelines including the steps of forward and back translation and expert committee consultations including Japanese family physicians, and other professionals with relevant expertise. Phase II: Twenty Japanese family physicians with speciality training in family medicine were recruited to use the translated SPICT (SPICT-JP) in their clinical practice. Interviews were conducted before and after they used the SPICT-JP at 4 to 7 months. The first interviews focused on their understanding of palliative care and identification of patients with palliative care needs. The second interviews captured their experiences and impressions of the utility of the SPICT-JP in their clinical practice and its potential application to improve palliative care within Japanese primary care. Results: Phase I: The SPICT was translated into Japanese (SPICT-JP). Any words and phrases identified in the translation process as not transferring well to Japanese language or clinical practice were discussed with a collaborator in Japan and supervisors in the UK including the original developers of the SPICT tool and consensus reached. Phase II: In general, the participating Japanese family physicians considered the principles of palliative care as being broad and relevant for patients with any kind of suffering which could potentially impair their quality of life. However, their application of the term ‘palliative care’ in routine practice was not consistent with this understanding. The term ‘palliative care’ seemed to be narrower, more context-dependent and sensitive to its public association with the imminence of death. The identification of patients with palliative care needs was a complex process incorporating many interconnected factors. The family physicians saw the transition to palliative care as an accumulation of changes, rather than ‘throwing a switch’. The SPICT-JP was perceived as being useful although it did not change the actual practice of the participating family physicians to any great extent. It seemed rather that the SPICT-JP reinforced the participants’ reflections on and in their practice and raised their awareness of the value of more systematic identification of patients with palliative care needs. They also appreciated having objective clinical criteria so that they did not have to rely on instinctive judgements based on personal experiences. Conclusions: There was a difference between how Japanese family physicians understand the principles of palliative care and their use of the term ‘palliative care’ in their actual clinical practice. The process of identification of patients with palliative care needs was complex, and a limited prognosis was not the only determinant. The SPICT-JP can potentially contribute to improved identification of patients with palliative care needs in the community by providing a focus and guidance to support for the assessments made by family physicians. More research is needed including with patients and their family carers to understand when and how it is best to identify patients with palliative care needs for holistic palliative care and care planning.