**8. Future family doctors' resourcefulness to meet the societal changes and the burden of home care in the modern family: academic medicine perspective**

Due to demographic changes, with increasing number of people in need of care and societal changes (decreased family size, more geographically dispersed families, erosion of barriers that previously could have kept couples together during difficult times, erosion of bonds between family generations, increasing number of people living alone), informal care structures are affected by considerable challenges [96]. In addition, the increase of urbanization, the rural-urban movement and the international migration profoundly affect the family structure and its involvement in providing long-term home care and providing a supportive environment.

Family caregivers involved in home care often face the challenge of balancing caregiving and job responsibilities. Involving older adults in caring for the elderly and children with disabilities and integrating informal caregivers, such as friends and neighbours, is valuable and requires strong intergenerational solidarity in the community. However, in low- and middle-income countries, chronic patients who seek support for maintaining independence and quality of life are often faced with a lack of health and social services, especially in rural areas, or in-home care with poor quality.

The availability of both in-home services (such as personal care and home healthcare) and community services (such as day programmes, congregate meals and social centres) enables a growing percentage of older recipients to delay or even avoid institutional care [97]. The shortage of formal and qualified caregivers presents a challenge for the future regarding the structure and organization of long-term care for most countries. The increasing number of care-dependent people leads to a high economic burden for most healthcare systems [98]. In order to support and facilitate family caregivers in their role of nursing, it is important to

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

the high-developed countries [88].

public healthcare system).

the community nurses and informal caregivers.

Basic or primary palliative care includes the following:

maintaining the functions and capacity for self-care

ing the treatment, and preferred place of death

patients such as cardiovascular or pulmonary diseases in need of PC in general practice, and these recipients require a valuable involvement of the informal caregivers from their families [91]. Despite the widely acknowledged importance of family doctors' engagement in primary PC [92], difficulties and even barriers were identified in the delivery of home-based PC in practice in our country as well as in

professionals, recipients of PC and family as provider of home-based PC. The impediments in the delivery of primary palliative care refer to:

of primary care offices in rural versus urban areas)

centre and lack of substitute in the medical office)

In a project developed in Romania in 2013–2016 by the Hospice of Hope, Brasov, with the financial support from the Swiss contribution to the enlarged European Union, barriers and ways to integrate a pilot model of basic palliative care in the healthcare system were identified [93]. Hospice of Hope, Brasov, is a Romanian non-profit organization, Centre of Excellence in PC for Eastern Europe and Central Asia, and one of the seven globally recognized models of palliative care. It develops palliative care at national and international levels through information, by improving the legislation in the field and through educational programmes dedicated to

• Structural barriers (e.g. family physicians and community nurses' shortage due to high emigration rates of junior doctors and nurses and unequal distribution

• Knowledge barriers (e.g. lack of skills and clinical routine in providing PC, practical obstacles in palliative training due to distance from the training

• Service barriers (e.g. lack of palliative care services for home care in some regions of the country, insufficient reimbursement of these services in the

Nationally, approximately 150,000 people with oncological diagnosis and other incurable diseases need home-based palliative care every year, but less than 7% of them benefit in a timely manner. During the project, the model of basic palliative care was tested in 4 pilot counties, on 26 family doctors trained for 6 months to provide palliative services to a number of 138 oncological patients treated at home. A guide of basic palliative care was developed and offered to the family doctors, contributing to the replication of the model in other counties and to the training of

Adopting the model of providing basic palliative care through family doctors can increase in the coming years, contributing to the palliative care needs assessment after diagnosing the incurable disease, not only in the end of life, and through specific interventions to increase the quality of life of these recipients in the community.

• Communicating the diagnosis and reasonable possibilities of treatment at home, identifying the treatment goals in agreement with the recipient and his/her family, controlling the symptoms of low to medium complexity and

• Involving the family caregivers in the home care, in making decisions regard-

• Treatment of symptoms due to chemo- and radiotherapy and their

**136**

complications

be carefully coordinated and their burden of care assessed by the comprehensive trained primary care health professionals.

Family physicians need a set of specific competences to perform well in interprofessional teams, and these competences should be achieved by graduating from a medical school [99]. Most medical schools have components of communication skills in the curriculum, but there are no clear standards for competence in communication skills, and the approach of interprofessional communication in the care team is limited. Beyond standardization of communication skills curricula, it is also necessary to verify primary care physicians' proficiency in interpersonal and interprofessional skills.

In some residency programmes, residents receive 360-degree evaluations which go beyond the typical assessment performed by the supervising attending physicians [100]. Such evaluations help residents better understand how they are viewed by those with whom they work and by those for whom they care. Family medicine residents' assessments are requested from the attending physicians and nurses and from the patients themselves who complete questionnaires from their perspective on the interaction of the resident doctor with the recipient and his family, obtaining 360-degree feedback from all those who have interacted with the resident functions as a valuable teaching tool in family medicine residency programme. Observations gained from multiple perspectives are believed to be more valid than individual opinion, and sharing them will likely have a positive effect on the development of physician trainees in family medicine and his future involvement in home care provision.

Academic medicine seeks to enhance training introducing new curricular areas dedicated to the development of interprofessional communication skills and resourcefulness in managing difficult circumstances in medical profession [101]. Future primary healthcare professionals, especially family doctors, should provide more comprehensive home care to their recipients, maintaining their independence and offering expected years of life free of disability.
