We used a scoping review approach to collect and describe peer-reviewed journal articles from the last 5 years [12, 13]. Due to the relatively new field of palliative care within the Primary Health Care setting within Australia, a scoping review methodology was used rather than a systematic review, as it was better suited to clarifying key concepts and identifying available evidence.

Peer-reviewed journal articles were retrieved through searching electronic databases. The database search strategy (SupplementaryAppendix S1) was developed and tested in PubMed with the help of a health Librarian. Broad text words and MeSH headings were used: palliative care, general practice, primary health, Australia, allied health personnel, and community setting. Extracted journal articles were limited to those based on the Australian population or Australian health system. A date limit of the last 5 years was applied due to time and resource constraints. Once the search was finalised and run in PubMed, it was then translated and run in Cinahl (Ebsco), Scopus, and Medline (Ovid) on 1 December 2020.

The search results for each database were uploaded into Endnote X9.3 reference management software and deduplicated. Journal articles were then imported into the web-based software Covidence for screening and data extraction.

Two reviewers (DvG and KEA) independently assessed titles and abstracts against the priori inclusion criteria outlined in Table 1. Where eligibility was unclear based on the title and abstract screening, the full text article was retrieved and assessed.

Criteria for inclusion were agreed upon by both reviewers (see Table 1.)

Two reviewers (DvG and KE-A) then defined exclusion criteria (Table 2) to exclude articles which were not relevant to the aim of the scoping review. Both reviewers then screened the full text against the exclusion criteria.

As the population ages, GPs and General Practice Nurses are increasingly expected to provide end-of-life care [16, 17]. As a natural extension of primary care, palliative care often includes GPs providing continuity of care by setting up an individualized care pathway from diagnosis to palliation, coordinating care across that pathway, and collaborating with other health care providers [18–22]. Hence, most General Practitioners are already practicing end-of-life care without recognising it [23]. Since GPs provide care throughout a patient’s lifetime they are well positioned to identify those with life-limiting illnesses and to address the needs of patients and caregivers [20, 24, 25].

The palliative care process is very complex and involves interactions between GPs and patients and their carers as well as other service providers both in the community and in acute care settings [20]. GPs are essential players in an integrated model of palliative care as they are often intimately familiar with patients and caregivers, expert in generalist care, and knowledgeable about health and social services in their local region [18, 26]. Team members vary depending on patients’ needs and local availability of health professionals, but in most cases, home-based palliative care teams are led and coordinated by the GP [27]. Health professional members include nurses, social workers, occupational therapists, other allied health professionals, and the local pharmacist, however if the patient is more complex, specialist palliative care services may be enlisted by the GP to complement the skills of the local team [27]. Therefore community based palliative care is often seen as a collaborative, integrative model incorporating generalist and specialist palliative care providers that is coordinated by a GP [28], often through interprofessional case conferences [16].

The GP role is diverse and includes symptom management, pain management and non-malignant disease management [16]. The GP is proactive in clinical care planning, anticipating and providing care as the person’s clinical condition deteriorates and as the goals of care shift from treating illness to comfort and death management [29]. Therefore, the GPs role also includes making referrals to specialist palliative care services [25, 30]. GPs are also often involved in end-of-life conversations, starting with establishing a strong doctor-patient relationship, gauging patients’ readiness to engage, and managing time availability [31]. Conversations usually start when a patient initiates them, when they are included in routine care, when they discuss prognosis or less directly inquire about the patients feelings about death [31]. GPs commit time and resource to assist their patients to create an end-of-life care plan [32], however, at times the end-of-life care plan is not explicitly articulated and discussed, so an informal care plan is developed gradually without discussing these plans with the patient [33].

With limited specialist palliative care resources available in the community, it is often GPs who provide and co-ordinate end-of-life care in collaboration with community-based support services [18]. This has resulted in the GP role differing slightly in urban versus rural settings due to resource limitations and lack of training [34]. Although inappropriate payment models discourage the involvement of GPs in certain end-of-life care aspects, such as case conferences and home visits, rural communities often indicate closer relationships between GPs and patients and better care integration and collaboration [34]. This points out the importance of providing GPs and rural/remote communities with support, education, incentives, better administrative tools, and options for advanced care planning [35].

Paramedics play an important role in community-based palliative care [36], their role is to treat patients who are experiencing health problems related to palliative care, such as pain and respiratory distress [37]. With Extended Care Paramedics responding to palliative care emergencies, and preventing unwanted and unnecessary hospitalisations [38]. In response to the increased use of Ambulance services in Australia to palliative care patients they are developing specific palliative care guidelines [37].

Patients’ caregivers usually know them best and are most motivated to help [27]. In the Primary Health Care setting, a palliative patient’s caregiver can provide assistance with activities of daily living, personal and domestic care, and shopping and household responsibilities [39]. Assistance may also include basic nursing care, as determined by the patient’s GP and the specialist palliative care team [39]. In addition, caregivers can have a role in managing medications for palliative care patients [40], and with training and support, can administer subcutaneous injections to relieve symptoms [41]. GP’s also play a role in supporting the carer, and as a result the Carer Supports Needs Assessment Tool is often integrated into palliative care within the Primary Health Care setting [42]. This tool facilitates support for family members and carers of adults with life-limiting conditions. In addition to indicating additional support they need, caregivers can also use this tool to indicate they need support for their own health and well-being in caring for a palliative care patient at home [42].

For older populations, Pharmacists can provide comprehensive health care at the end of life [43]. The Pharmacist plays a key role in ensuring that palliative care patients receive the best possible medication management [44], with community pharmacies providing medication for managing symptoms of the terminal phase [45]. Medication management for long term palliative care occurs as an interdisciplinary collaboration between pharmacists, GP’s, carers and other health professionals [46, 47], with improved management occurring when pharmacists are engaged in anticipation of the terminal phase [45, 48, 49]. Tait and Cheung [50] identified six key themes to improve community access to terminal phase medicines in Australia: medication supply, education and training, caregiver burden, safety, funding and clinical governance.

There are several well-defined nursing roles undertaking palliative care within the primary health setting. With adequate training and support, General Practice Nurses are able to initiate and facilitate advanced care planning conversations with patients [51]. In those cases where access to specialists is difficult, Advance Nurses provide specialized care [52]. With their knowledge of rural health resources available to patients, District Nurses are an expert advocate for implementing a person-centred goal plan for rural palliative patients [53]. Nurse practitioner coordinated palliative care appears to enable more integrated care which extends the potential for collaborative primary care and may be effective in reducing hospitalisations [54, 55]. Providing physical care to patients, managing symptoms and educating families are often roles undertaken by Specialist Nurses [56].

To a lesser extent, the review has also highlighted the importance of specific allied health professionals in the provision of physical care (optimising function and nonpharmacological symptom management), social, emotional, and spiritual care [57] of palliative care patients within the primary health setting. Having Advanced Care Planner Facilitators within general practices can positively impact end-of-life care experience by referring patients to supportive programs and facilitating advance care planning [58].

Our scoping review benefits from several strengths. Firstly, the scoping literature review search was undertaken by a professional health librarian. The study selection process was verified by a second reviewer to ensure the inclusion and exclusion criteria were applied accurately. The scoping literature review has been a useful way to synthesise a broad range of research evidence about palliative care within the Primary Health Care setting within Australia. However, this scoping literature review would have benefitted from a search of grey literature to yield insights into broader aspects of palliative care within the Primary Health Care setting.

A limitation of this review is that the literature surveyed was limited to Australia only. However, this provides a good national example of palliative care within the Primary Health Care setting which could be adopted by other countries.

This scoping review has identified health professional roles and their scope of practice in providing palliative care within the Primary Health Care setting within Australia. It has also provided examples of models of care which support people with life-limiting illness engage with other services and health professionals within the Primary Heath Care setting and across other health care settings.