The first time it happened I couldn’t believe it. I was watching a GP hand a grieving family their loved one’s death certificate…in a carpark. Instead of visiting them at their home — instead of showing respect for his deceased patient — he was meeting them in the carpark of his practice. He signed the death and cremation certificates, and, with barely a word, was gone. I was instantly saddened by what looked to be nothing more than a transaction.
Unfortunately, as a funeral director I know that this exact scene happens far more frequently than it should. I’m seeing more and more GPs give way to greed, and finding themselves motivated by money and convenience in place of professional obligation and continuity of care. It's not only impacted patients and their families, but the general quality of GP support in nursing homes. When you consider that around 170,000 elderly Australians are currently living in aged care (a figure that’s not expected to drop any time soon), it’s more critical than ever that we address issues surrounding duty of care...and start providing the support that patients deserve.
Processing the news of a loved one’s death is already a whirlwind of emotion and stress, and fraught with many sudden arrangements and responsibilities. The last thing a family needs to worry about is being left high and dry, while waiting for a GP to attend the deceased.
Like most people, I strongly believe in dying with dignity — which is why I want to explain the rights you have as an individual or loved one when it comes to GP obligations to the deceased in nursing homes.
Your first call should be to a GP
When a person dies at a nursing home and the death is expected, the first person that should be notified is their GP. The patient’s GP must attend as quickly as possible so that the death certificate (and cremation certificate, if required) can be issued. Only once this has taken place can the deceased be transported to the funeral home. However, given the busy schedules of Australian GPs, it's not always possible for them to attend on the spot. In these cases, nursing home staff may call an after-hours doctor (who may also be limited in availability), or issue a life extinct certificate themselves.
But this is where things get tricky. First and foremost, not all nurses are authorised to issue the life extinct certificate themselves, and, even in the case they are, registered nurses are unable to provide a cremation certificate. Secondly, Medicare provides payment for the death certificate and not the cremation certificate. Therefore, GPs often require the funeral director to visit their practice to provide payment first before receiving the certificate — compulsory immediate payment is a practice that needlessly delays the process of caring for the deceased.
Unfortunately, these are the better case scenarios for many families. If no GPs respond immediately, the nurse must wait helplessly with the body until a doctor is free. During that time, the deceased is left to lay there, dormant and undignified; almost abandoned by the very system created to support them.
Most nursing homes aren’t equipped with mortuary facilities that can hold deceased residents. In desperation, nursing home staff are sometimes forced to call the police to have a body moved. That can be advantageous in the sense that a coroner will legally issue the death certificate — but it's certainly not the most sensitive way to deal with the peacefully deceased, or the grieving families who are confronted by this scene. In some cases the area may end up being cordoned off as a crime scene, simply due to police protocols.
One can only imagine how distressing that experience would be to the to families, residents and staff present at the time. Surely resources could be managed more effectively!
The business of medical care
We all know that GPs are busy. However, when it comes to performing simple, administrative tasks such as signing a death certificate - which they are paid to do like any other service - why are they so scarcely available?
It’s no use calling an after hours doctor as they are there to look after the ill. There is nothing more they can do to someone who is passed away. Let them attend to the ill after hours.
A 2012 AMA report found that over two-thirds of the GPs surveyed had decreased their visits to nursing homes — with the majority attributing this to the non-billable hours and inadequate Government rebates associated with callout visits. But the problem is much broader: last year it was reported that roughly 80% of GPs refuse to offer after-hours visits to the general public at all because of the additional costs incurred by doctors. That's why most house calls are now handled by private medical deputizing services (companies that employ registered medical practitioners to provide after-hours services) who offer no continuity of care, and have even been under attack for allegedly sending unqualified GPs to treat home visit patients.
The role our politicians play
The Australian Government tried to incentivise GPs to provide services to aged care facilities back in 2008, with the launch of the Aged Care Access Incentive. This was designed to provide financial support for GPs who offer ongoing services in Residential Aged Care Facilities. Unfortunately, the impact of this incentive has been minimal; as of 2014 there was still only one ACAI GP for every 34 residents. Was it a poorly designed policy? Or was it simply not enough money offered to doctors in order to convince them to treat elderly patients?
Before we go pointing the finger exclusively at Australian GPs, it's important to recognise that this is a worldwide trend. For instance: in 2015, the Daily Mail reported that GPs were demanding fees of up to £100,000 a year to visit elderly patients; essentially applying a surcharge on the grounds that they were providing an ‘enhanced service’ for nursing home visits. This overwhelmingly ignored the fact that UK GPs already receive subsidies to service nursing homes, as part of the National Health Service’s funding system.
The good news is that the Australian Government has since funded new initiatives to help GPs monitor and interact with elderly patients (including the development of palliative care apps and video consultation software). But while this technology will undoubtedly improve doctors’ abilities to monitor elderly patients, it could also widen the gulf between them. In their 2016 General Practice in Primary Health Care Position Statement, the AMA argued that:
“Having a regular GP...enables the long-term and continuous care of a patient through an ongoing relationship of respect and trust. Treating someone face-to-face and not via technology from afar, in my opinion, is the only way to truly show that respect and trust.”
This is compounded by the fact that many older people don’t feel comfortable with using technology; unlike younger generations, as they have not been brought up with the internet, Facebook or online shopping. So when it comes to healthcare, doctor-patient relationships are something that is a face to face conversation, not integrated with technology.
We need to talk about dying
One of the reasons why I became a funeral director was to provide people with genuine, human, support at a time when I knew they needed it most. I don’t feel it’s unreasonable for Australians to expect their GPs provide the same — especially when it comes to aged care, palliative care and dying, from someone who may have serviced the family through all their other medical needs throughout life.
If you are unsure or concerned about the ability for you, a loved one or a patient you care for to access GP services in an aged care facility, don’t be afraid to ask questions. It’s not always the easiest conversation, but it is a critical one. At Lady Anne, we created a Funeral Planning Checklist, which anyone can download, in the hope that it would help people face these difficult discussions head on, and to know the processes and rights of the family of the deceased.
Remember: living and dying with dignity are rights that everyone should have...which is why it’s mind-boggling to imagine how some GPs don’t adhere to those same, core human values. After all, if treating the deceased with dignity and respect isn't the priority of a medical professional, then I can only assume they're not a true professional at all.