Recommendations from evaluating the implementation of the 'GP Daffodil Standards' to support the provision of palliative and end-of-life care in primary care: a mixed-methods study.

BACKGROUND: The 'GP Daffodil Standards for Advanced Serious Illness and End of Life Care' was launched by the Royal College of General Practitioners and Marie Curie in 2019 to support improvement of end-of-life care activity in primary care. AIM: To undertake and independent evaluation of the implementation of the Daffodil Standards. METHOD: A multi-method evaluation, informed by Normalisation Process Theory. An online survey with GPs in the UK (Phase 1) and semi-structured interviews with a sub-sample of survey responders (Phase 2) were used to map end-of-life activities and understand the use of the standards. Illustrative case studies of good practice were used to outline recommendations to improve and sustain the implementation of the standards (Phase 3). Data were analysed both quantitatively (Phase 1: descriptive statistics) and qualitatively (Phases 2 and 3: framework analysis). RESULTS: For the Phase 1 survey (n = 82) and Phase 2 semi-structured interviews (n = 8), results demonstrated the motivation to undertake end-of-life care activities and active use of the standards. GPs find it difficult to take this further because of limitations in resources and capacity. There is the indication that a misperception exists for both the purpose and role of the standards. For Phase 3, two case studies are complete, providing more in-depth practical insights into the planning, use, and implementation of the standards. All data collection stopped in December 2023. CONCLUSION: Final results were reported and best practice shared, along with recommendations to sustain the ongoing implementation of the Daffodil Standards.

Lockjaw from a metastatic uterine leiomyosarcoma- case report and review of the literature.

BACKGROUND: Leiomyosarcoma (LMS) is a malignant tumour formed of cells with distinct smooth muscle features. Leiomyosarcomas rarely metastasise to the oral cavity and this literature review details all reported cases of metastasis to the mandible found in the literature. This offers a unique perspective by specifying mandible as the site of metastasis of leiomyosarcoma. CASE PRESENTATION: A 53-year-old female presented to her General Practitioner (GP) with heavy menstrual bleeding and was diagnosed with multiple fibroids. Folowing a hysterectomy and removal of both tubes and ovaries for these symptomatic uterine fibroids, an incidental diagnosis of low grade leiomyosarcoma was made. A CT scan found no evidence of residual or metastatic disease and no further treatment was deemed necessary. 6 months later she presented to A & E with a numb lower lip but it took another 6 months for the diagnosis of metastatic LMS to the mandible to be made. DISCUSSION: Leiomyosarcomas are aggressive tumours which are liable to metastasise and therefore have a poor prognosis. An extensive literature review was undertaken to explore the frequency of metastasis in the maxillo-facial region. CONCLUSIONS: Although metastasis to the oral region is very rare as suggested from the literature review, when patients present with unusual symptoms after a diagnosis of LMS, physicians should be aware of the possibility of LMS metastases.