Many factors may hamper optimal pain management such as patient nonadherence to drug therapy, underreporting of pain or miscommunication between patient and caregivers; from a healthcare provider perspective, inadequate assessment of pain, poor documentation and miscommunication may limit optimal pain management . To achieve good patient care at the end of life, also adequate knowledge of pain management and opioids among physicians is essential. Pain is still one of the most frequently occurring symptoms at the end of life, although it can be treated satisfactorily in most cases if the physician has adequate knowledge [2–7].
Among countries, different physicians are involved in pain treatment at the end of life. In the Netherlands, health care is characterised by its strong emphasis on primary care, where the family physician is the central professional in the management and coordination of the patient's care . Almost 60% of the patients with non-acute illnesses die at home where palliative care is coordinated by the general practitioner (GP) . About 30% of the patients with non-acute illnesses die in hospitals (cared for by clinical specialists), and about 10% in nursing homes (where the elderly care physician - formerly known as nursing home physician - is responsible) . It is estimated that 5% of all people die in a specialised palliative care unit. These units are part of nursing homes or homes for the elderly (50%), or hospices (50%) . Characteristic for the Netherlands is that euthanasia is a legal option when suffering is unbearable and hopeless; in 2005, 1.7% of all deaths was the result of euthanasia .
Elderly care physicians usually work in a single organisation, and are trained to care for elderly patients, including end of life care [12, 13]. A wide range of clinical specialists provide end of life care in hospitals, and they also consult their colleagues in general practice and nursing homes to discuss complex symptoms in end of life care: for example 55% of the GPs cooperate with a clinical specialist . In palliative home care, GPs frequently cooperate with district nurses and can consult a regionally working palliative care consultation team .
In all these settings, possibilities to treat patients at the end of life with medication have increased in the past decade. Being able to take advantage of these possibilities does require physicians to maintain their knowledge. Guidelines that are developed by medical professional organizations can be a useful tool for this purpose.
Initially, there was optimism that the availability of evidence-based guidelines about pain management at the end of life would lead to great improvements in care. Research in the US showed that the problem of suboptimal pain management was far more complex than previously suspected: certain myths about the benefit of pain and the disadvantages and limitations of treatment of pain are to such an extent assimilated in the collective knowledge, that they are not banished by simply stating in a guideline that they are false . Examples of such widespread myths are that pain often is inevitable, that administering increasing dosages of opioids hastens the end of life, and that adverse effects of opioids, such as drowsiness and confusion are inevitable [16–24].
In the international literature, the main focus of the effect of such myths is that opioids are underdosed, as a consequence of which patients may suffer needlessly [16, 20, 21]. Studies in the Netherlands have also shown that physicians treating cancer pain do not always follow evidence-based guidelines [25–27]. Another risk of myths can be that physicians overdose opioids, e.g. if they intend to hasten the end of life, and think they can attain this goal by increasing the dosage further than is required for pain management.
Developing and dispersing evidence-based guidelines is an important step towards an evidence-based practice, but further steps are required. To improve the quality of care at the end of life, it is subsequently necessary to study which knowledge has and which has not permeated to physicians, and which myths may hinder further permeation.
We aimed to study the level of knowledge of physicians, including both knowledge that should be familiar ground to all physicians, and facts that have more recently been added to the body of evidence, but should also be known to physicians involved in end of life care. Furthermore, we aimed to study experiences of physicians with pain management and opioids at the end of life, and possible barriers to good pain management at the end of life according to physicians.