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Evans CJ, Yorganci E, Lewis P, Koffman J, Stone K, Tunnard I, Wee B, Bernal W, Hotopf M, Higginson IJ. Processes of consent in research for adults with impaired mental capacity nearing the end of life: systematic review and transparent expert consultation (MORECare_Capacity statement). BMC Med 2020; 18:221. [PMID: 32693800 PMCID: PMC7374835 DOI: 10.1186/s12916-020-01654-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/03/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Involving adults lacking capacity (ALC) in research on end of life care (EoLC) or serious illness is important, but often omitted. We aimed to develop evidence-based guidance on how best to include individuals with impaired capacity nearing the end of life in research, by identifying the challenges and solutions for processes of consent across the capacity spectrum. METHODS Methods Of Researching End of Life Care_Capacity (MORECare_C) furthers the MORECare statement on research evaluating EoLC. We used simultaneous methods of systematic review and transparent expert consultation (TEC). The systematic review involved four electronic databases searches. The eligibility criteria identified studies involving adults with serious illness and impaired capacity, and methods for recruitment in research, implementing the research methods, and exploring public attitudes. The TEC involved stakeholder consultation to discuss and generate recommendations, and a Delphi survey and an expert 'think-tank' to explore consensus. We narratively synthesised the literature mapping processes of consent with recruitment outcomes, solutions, and challenges. We explored recommendation consensus using descriptive statistics. Synthesis of all the findings informed the guidance statement. RESULTS Of the 5539 articles identified, 91 met eligibility. The studies encompassed people with dementia (27%) and in palliative care (18%). Seventy-five percent used observational designs. Studies on research methods (37 studies) focused on processes of proxy decision-making, advance consent, and deferred consent. Studies implementing research methods (30 studies) demonstrated the role of family members as both proxy decision-makers and supporting decision-making for the person with impaired capacity. The TEC involved 43 participants who generated 29 recommendations, with consensus that indicated. Key areas were the timeliness of the consent process and maximising an individual's decisional capacity. The think-tank (n = 19) refined equivocal recommendations including supporting proxy decision-makers, training practitioners, and incorporating legislative frameworks. CONCLUSIONS The MORECare_C statement details 20 solutions to recruit ALC nearing the EoL in research. The statement provides much needed guidance to enrol individuals with serious illness in research. Key is involving family members early and designing study procedures to accommodate variable and changeable levels of capacity. The statement demonstrates the ethical imperative and processes of recruiting adults across the capacity spectrum in varying populations and settings.
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Affiliation(s)
- C J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK.
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK.
| | - E Yorganci
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - P Lewis
- Centre of Medical Law and Ethics, The Dickson Poon School of Law, King's College London, London, UK
| | - J Koffman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - K Stone
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - I Tunnard
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - B Wee
- Oxford University Hospitals NHS Foundation Trust and Harris Manchester College, University of Oxford, Oxford, UK
| | - W Bernal
- King's College Hospital, London, UK
| | - M Hotopf
- Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - I J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
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Barbato M, Barclay G, Potter J, Yeo W. Sedation and Analgesia in Unconscious Palliative Care Patients: Can Bispectral Index monitoring add to our understanding? J Palliat Care 2017; 31:57-9. [DOI: 10.1177/082585971503100109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael Barbato
- Palliative Care Unit, Port Kembla Hospital, 89–91 Cowper Street, Warrawong, New South Wales 2505, Australia
| | - Greg Barclay
- Palliative Care Services, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Port Kembla Hospital, Warrawong, New South Wales, Australia
| | - Jan Potter
- Geriatric Medicine, Aged Care, Rehabilitation and Palliative Care, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia; Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Wilf Yeo
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Clinical Research and Trial Unit, Illawarra Health and Medical Research Institute, University of Wollongong Campus, Wollongong, New South Wales, Australia
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Dotolo D, Nielsen EL, Curtis JR, Engelberg RA. Strategies for Enhancing Family Participation in Research in the ICU: Findings From a Qualitative Study. J Pain Symptom Manage 2017; 54:226-230.e1. [PMID: 28438584 PMCID: PMC5557665 DOI: 10.1016/j.jpainsymman.2017.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 02/23/2017] [Accepted: 03/22/2017] [Indexed: 11/17/2022]
Abstract
CONTEXT Family members of critically ill patients who participate in research focused on palliative care issues have been found to be systematically different from those who do not. These differences threaten the validity of research and raise ethical questions about worsening disparities in care by failing to represent diverse perspectives. OBJECTIVES This study's aims were to explore: 1) barriers and facilitators influencing family members' decisions to participate in palliative care research; and 2) potential methods to enhance research participation. METHODS Family members who were asked to participate in a randomized trial testing the efficacy of a facilitator to improve clinician-family communication in the intensive care unit (ICU). Family members who participated (n = 17) and those who declined participation (n = 7) in Family Communication Study were interviewed about their recruitment experiences. We also included family members of currently critically ill patients to assess current experiences (n = 4). Interviews were audio-recorded and transcribed. Investigators used thematic analysis to identify factors influencing family members' decisions. Transcripts were co-reviewed to synthesize codes and themes. RESULTS Three factors influencing participants' decisions were identified: Altruism, Research Experience, and Enhanced Resources. Altruism and Research Experience described intrinsic characteristics that are less amenable to strategies for improving participation rates. Enhanced Resources reflects families' desires for increased access to information and logistical and emotional support. CONCLUSION Family members found their recruitment experiences to be positive when staff were knowledgeable about the ICU, sensitive to the stressful circumstances, and conveyed a caring attitude. By training research staff to be supportive of families' emotional needs and need for logistical knowledge about the ICU, recruitment of a potentially more diverse sample of families may be enhanced.
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Affiliation(s)
- Danae Dotolo
- School of Social Work, University of Washington, Seattle, Washington, USA.
| | - Elizabeth L Nielsen
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
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Jones TA, Olds TS, Currow DC, Williams MT. Feasibility and Pilot Studies in Palliative Care Research: A Systematic Review. J Pain Symptom Manage 2017; 54:139-151.e4. [PMID: 28450220 DOI: 10.1016/j.jpainsymman.2017.02.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 01/13/2017] [Accepted: 02/20/2017] [Indexed: 12/19/2022]
Abstract
CONTEXT Feasibility and pilot study designs are common in palliative care research. Finding standard guidelines on the structure and reporting of these study types is difficult. OBJECTIVES In feasibility and pilot studies in palliative care research, to determine 1) how commonly a priori feasibility are criteria reported and whether results are subsequently reported against these criteria? and 2) how commonly are participants' views on acceptability of burden of the study protocol assessed? METHODS Four databases (OVID Medline, EMBASE, CINAHL, and PubMed via caresearch.com.au.) were searched. Search terms included palliative care, terminal care, advance care planning, hospice, pilot, feasibility, with a publication date between January 1, 2012 and December 31, 2013. Articles were selected and appraised by two independent reviewers. RESULTS Fifty-six feasibility and/or pilot studies were included in this review. Only three studies had clear a priori criteria to measure success. Sixteen studies reported participant acceptability or burden with measures. Forty-eight studies concluded feasibility. CONCLUSION The terms "feasibility" and "pilot" are used synonymously in palliative care research when describing studies that test for feasibility. Few studies in palliative care research outline clear criteria for success. The assessment of participant acceptability and burden is uncommon. A gold standard for feasibility study design in palliative care research that includes both clear criteria for success and testing of the study protocol for participant acceptability and burden is needed. Such a standard would assist with consistency in the design, conduct and reporting of feasibility and pilot studies.
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Affiliation(s)
- Terry A Jones
- School of Health Sciences and Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, South Australia, Australia.
| | - Timothy S Olds
- School of Health Sciences and Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, South Australia, Australia
| | - David C Currow
- Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Marie T Williams
- School of Health Sciences and Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, South Australia, Australia
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Guardia-Mancilla P, Montoya-Juárez R, Expósito-Ruiz M, Hueso-Montoro C, García-Caro MP, Cruz-Quintana F. Variability in professional practice among departments explains the type of end-of-life care but not the difficulty of professionals with decision-making / La variabilidad de la práctica profesional entre los departamentos explica el tipo de cuidados sanitarios al final de la vida, pero no las dificultades que afrontan los profesionales respecto de la toma de decisiones. STUDIES IN PSYCHOLOGY 2017. [DOI: 10.1080/02109395.2017.1328845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Snowden A, Young J. A screening tool for predicting gatekeeping behaviour. Nurs Open 2017; 4:187-199. [PMID: 29085645 PMCID: PMC5653390 DOI: 10.1002/nop2.83] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/28/2017] [Indexed: 11/30/2022] Open
Abstract
Aim To develop a typology and screening tool for gatekeeping behaviours by nurses responsible for recruitment in palliative care research. Design Concurrent analysis. Method Two focus groups were conducted in 2015 with nine qualified hospice community nurses involved in recruitment to a trial in palliative care. The literature was searched for research into gatekeeping from 2000–2016. All narrative examples of gatekeeping activity were coded using gerunds. Common codes were then grouped and interpreted as a social process. Results Gatekeeping is normal and should be expected. A continuum typology emerged, ranging from unintentional to active disengagement. Justification ranged from forgetting to deliberately not mentioning the study for fear of burdening patients. Viewing gatekeeping as a continuum allowed for the creation of a screening tool designed to collaboratively discuss and hence mitigate specific types of gatekeeping behaviour before they occur. This is a unique international contribution to this persistent issue.
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Affiliation(s)
| | - Jenny Young
- Edinburgh Napier University Edinburgh EH11 4BN UK
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L Campbell C, Bailey C, Armour K, Perry R, Orlando R, Kinghorn P, Jones L, Coast J. A team approach to recruitment in hospice research: engaging patients, close people and health professionals. Int J Palliat Nurs 2016; 22:324-32. [DOI: 10.12968/ijpn.2016.22.7.324] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Cathy L Campbell
- Associate Professor, University of Virginia, School of Nursing Charlottesville, VA, US
| | - Cara Bailey
- Senior Lecturer in Nursing, School of Nursing, Institute of Clinical Sciences, University of Birmingham, West Midlands, UK
| | | | - Rachel Perry
- Research Nurse, Marie Curie Hospice, Solihull, West Midlands, UK
| | - Rosanna Orlando
- Health Economist Research Fellow, CLAHRC Wessex, University of Southampton, UK
| | - Philip Kinghorn
- Research Fellow, Health Economics Unit, Institute of Applied Health Research, University of Birmingham, UK
| | - Louise Jones
- Clinical Senior Lecturer, University College London, UK
| | - Joanna Coast
- Professor, School of Social and Community Medicine, University of Bristol, UK
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Kars MC, van Thiel GJ, van der Graaf R, Moors M, de Graeff A, van Delden JJ. A systematic review of reasons for gatekeeping in palliative care research. Palliat Med 2016; 30:533-48. [PMID: 26577927 DOI: 10.1177/0269216315616759] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND When healthcare professionals or other involved parties prevent eligible patients from entering a trial as a research subject, they are gatekeeping. This phenomenon is a persistent problem in palliative care research and thought to be responsible for the failure of many studies. AIM To identify potential gatekeepers and explore their reasons for gatekeeping in palliative care research. DESIGN A 'Review of Reasons' based on the systematic Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach and a thematic synthesis. DATA SOURCE PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO from 2000 to May 20 2015 were searched. Studies in children (aged <18 years) and patients with dementia were excluded. RESULTS Thirty papers on gatekeeping in palliative care research were included. Five groups of potential gatekeepers were identified: healthcare professionals, research ethics committees, management, relatives and researchers. The fear of burdening vulnerable patients was the most reported reason for gatekeeping. Other reasons included 'difficulty with disclosure of health status', 'fear of burdening the patient's relatives', 'doubts about the importance or quality of the study', 'reticent attitude towards research and (research) expertise' and 'logistics'. In hospice and homecare settings, the pursuit of comfort care may trigger a protective attitude. Gatekeeping is also rooted in a (perceived) lack of skills to recruit patients with advanced illness. CONCLUSION Gatekeeping is motivated by the general assumption of vulnerability of patients, coupled with an emphasis on the duty to protect patients. Research is easily perceived as a threat to patient well-being, and the benefits appear to be overlooked. The patients' perspective concerning study participation is needed to gain a full understanding and to address gatekeeping in palliative care research.
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Affiliation(s)
- Marijke C Kars
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ghislaine Jmw van Thiel
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marleen Moors
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes Jm van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Hanson LC, Bull J, Wessell K, Massie L, Bennett RE, Kutner JS, Aziz NM, Abernethy A. Strategies to support recruitment of patients with life-limiting illness for research: the Palliative Care Research Cooperative Group. J Pain Symptom Manage 2014; 48:1021-30. [PMID: 24863152 PMCID: PMC4241388 DOI: 10.1016/j.jpainsymman.2014.04.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/31/2014] [Accepted: 04/23/2014] [Indexed: 10/25/2022]
Abstract
CONTEXT The Palliative Care Research Cooperative Group (PCRC) is the first clinical trials cooperative for palliative care in the U.S. OBJECTIVES To describe barriers and strategies for recruitment during the inaugural PCRC clinical trial. METHODS The parent study was a multisite randomized controlled trial enrolling adults with life expectancy anticipated to be one to six months, randomized to discontinue statins (intervention) vs. to continue on statins (control). To study recruitment best practices, we conducted semistructured interviews with 18 site principal investigators (PIs) and clinical research coordinators (CRCs) and reviewed recruitment rates. Interviews covered three topics: 1) successful strategies for recruitment, 2) barriers to recruitment, and 3) optimal roles of the PI and CRC. RESULTS All eligible site PIs and CRCs completed interviews and provided data on statin protocol recruitment. The parent study completed recruitment of 381 patients. Site enrollment ranged from 1 to 109 participants, with an average of 25 enrolled per site. Five major barriers included difficulty locating eligible patients, severity of illness, family and provider protectiveness, seeking patients in multiple settings, and lack of resources for recruitment activities. Five effective recruitment strategies included systematic screening of patient lists, thoughtful messaging to make research relevant, flexible protocols to accommodate patients' needs, support from clinical champions, and the additional resources of a trials cooperative group. CONCLUSION The recruitment experience from the multisite PCRC yields new insights into methods for effective recruitment to palliative care clinical trials. These results will inform training materials for the PCRC and may assist other investigators in the field.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina, USA; Cecil B. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.
| | - Janet Bull
- Four Seasons Hospice and Palliative Care, Flat Rock, North Carolina, USA
| | - Kathryn Wessell
- Cecil B. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lisa Massie
- Four Seasons Hospice and Palliative Care, Flat Rock, North Carolina, USA
| | - Rachael E Bennett
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Noreen M Aziz
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Amy Abernethy
- Division of Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Rainsford S, Bullen T, Rosenberg J. Challenges of recruiting hospice inpatients with advanced cancer to research: Reflections on a delirium screening study. PROGRESS IN PALLIATIVE CARE 2014. [DOI: 10.1179/1743291x14y.0000000089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Reid C, Gibbins J, Bloor S, Burcombe M, McCoubrie R, Forbes K. Healthcare professionals' perspectives on delivering end-of-life care within acute hospital trusts: a qualitative study. BMJ Support Palliat Care 2013; 5:490-5. [PMID: 24644187 DOI: 10.1136/bmjspcare-2013-000468] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 09/09/2013] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The quality of end-of-life (EOL) care in acute hospitals is variable and interventions to improve this care, such as EOL care pathways, are not always used. The underlying reasons for this variability are not fully understood. We explored healthcare professionals' views on delivering EOL care within an acute hospital trust in the South West of England. METHODS We employed qualitative methods (focus groups, in-depth interviews and questerviews) within a study investigating the impact of a simple EOL tool on the care of dying patients. We invited a range of staff of all grades with experience in caring for dying patients from medicine, surgery and care of the elderly teams to participate. RESULTS Six focus groups, seven interviews and five questerviews were conducted. Two main themes emerged: (a) delays (difficulties and avoidance) in diagnosing dying and (b) the EOL tool supporting staff in caring for the dying. Staff acknowledged that the diagnosis of dying was often made late; this was partly due to prognostic uncertainty but compounded by a culture that did not acknowledge death as a possible outcome until death was imminent. Both the medical and nursing staff found the EOL tool useful as a means of communicating ceilings of care, ensuring appropriate prescribing for EOL symptoms, and giving nurses permission to approach the bedside of a dying patient. CONCLUSIONS The culture of avoiding death and dying in acute hospitals remains a significant barrier to providing EOL care, even when EOL tools are available and accepted by staff.
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Affiliation(s)
- Colette Reid
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - Jane Gibbins
- Cornwall Hospice Care, St Julia's Hospice, Hayle, Cornwall, UK
| | - Sophia Bloor
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - Melanie Burcombe
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - Rachel McCoubrie
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - Karen Forbes
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
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