What Factors Assist Clinicians to Determine Dying in an Acute Hospital?

October 22, 2015

downloadWhen I first started my DPhil journey I was concerned that the End of Life Care Strategy (2008) End of Life Care Strategy (2008) stated that there should be a reduction of expected deaths in the acute setting. In order to achieve this goal, when it has been identified that the patient’s preferred place of care is home, I felt that clinicians needed to be able to recognise when a patient is dying. The aims of this study were therefore to identify factors that help or hinder a clinician when they are trying to recognise when irreversible dying begins.

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I developed a 3 phase mixed methods study.
Phase 1: a systematic review of current primary research.
Phase 2: unstructured interviews with clinicians in the acute setting using the Grounded Theory approach to analysis.
Phase 3: a Delphi study to identify which of these factors would be useful in an education programme.

Four themes were identified within the systematic review. “Patient Observation” and “Knowledge of the Patient” were identified as facilitators in this recognition process whereas “Communication” and “Attitudes of the Clinician” were identified as being facilitators when positive but also having the potential to be barriers when held in a negative context.

The findings of the interviews complimented these findings expanding on the theme “Attitudes of the Clinician” in particular, placing an equal emphasis on the attitudes of the patient and their families to that of the clinician. The interviews identified a fifth theme, “Experience of the Clinician”. The over-arching theory emerging from the interviews was that clinicians have a fear of getting the timing of the recognition of the irreversible dying phase wrong and therefore fear they may withdraw or withhold treatment inappropriately.

I then developed a theoretical model based on the social cognitive theory which suggests that behaviours can be explained in terms of three key concepts which continuously interact. The three concepts are cognitive, behavioural and environmental factors. The themes and factors where consensus had been achieved that they warranted inclusion in an education package were translated into this model.

I feel that there may be potential in the development of a complex intervention using a combination of interactive workshops using case studies covering the multi professional team as a way forward to improve clinical skills in this area.

However, some factors identified related more to shifting the culture and philosophy of both the health care setting and the wider community (E.g taboo subject within this society, medical philosophy of cure and the courage to challenge the current systems in place). Change of culture and philosophy are problematic areas in which to effect change effectively.

This study high-lighted that there is a paucity of robust research available in end of life care on which clinicians can base their decision making. This has potentially has resulted in there being areas where even the experts have difficulty achieving consensus as practice has grown up reflecting local needs. This is evidenced in this study where there were topics identified by experts for inclusion in the questionnaire as they were thought to be important topics the panel was then unable to achieve consensus regarding this. I was also able to identify factors that clinicians feel are barriers or facilitators in the recognition of the patient who is irreversibly dying. It has also identified which of these factors would be useful for inclusion in a complex intervention for clinicians in order to improve their practice in this area. There has also been the outcome of the identification of the impact that the cultural attitude to death and dying of society as a whole has on this process. I hope this study can now be used as the evidence base for the next stages of development of a complex intervention of an education package.

About Joan “Frankie” Dee
I have worked at St Luke’s Hospice in Plymouth for the last 25 years, initially as a staff nurse. I have held various roles here amongst which are Matron and Head of Nursing.  Currently am the
for the organisation. I came late to academia completing my MSc in Evidence Based Health Care at Oxford in 2007 and my Doctorate in 2015.

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