Clinical decision making in the recognition of dying: a qualitative interview study

Taylor, Paul; Dowding, Dawn; Johnson, Miriam

Abstract

Background: Recognising dying is an essential clinical skill for general and palliative care professionals alike. Despite the high importance, both identification and good clinical care of the dying patient remains extremely difficult and often controversial in clinical practice. This study aimed to answer the question: “What factors influence medical and nursing staff when recognising dying in end-stage cancer and heart failure patients?” Methods: This study used a descriptive approach to decision-making theory. Participants were purposively sampled for profession (doctor or nurse), specialty (cardiology or oncology) and grade (senior vs junior). Recruitment continued until data saturation was reached. Semi-structured interviews were conducted with NHS medical and nursing staff in an NHS Trust which contained cancer and cardiology tertiary referral centres. An interview schedule was designed, based on decision-making literature. Interviews were audio-recorded and transcribed and analysed using thematic framework. Data were managed with Atlas.ti. Results: Saturation was achieved with 19 participants (7 seniors; 8 intermediate level staff; 4 juniors). There were 11 oncologists (6 doctors, 5 nurses) and 8 cardiologists (3 doctors, 5 nurses). Six themes were generated: information used; decision processes; modifying factors; implementation; reflecting on decisions and related decisions. The decision process described was time-dependent, ongoing and iterative, and relies heavily on intuition. Conclusions: This study supports the need to recognise the strengths and weaknesses of expertise and intuition as part of the decision process, and of placing the recognition of dying in a time-dependent context. Clinicians should also be prepared to accept and convey the uncertainty surrounding these decisions, both in practice and in communication with patients and carers.

Citation

Taylor, P., Dowding, D., & Johnson, M. (2017). Clinical decision making in the recognition of dying: a qualitative interview study. BMC Palliative Care, 16(11), Article ARTN 11. https://doi.org/10.1186/s12904-016-0179-3

• Journal Article Type: Article
• Acceptance Date: Dec 23, 2016
• Online Publication Date: Jan 25, 2017
• Publication Date: Jan 25, 2017
• Deposit Date: Oct 25, 2016
• Publicly Available Date: Jan 25, 2017
• Journal: BMC palliative care
• Print ISSN: 1472-684X
• Publisher: Springer Verlag
• Peer Reviewed: Peer Reviewed
• Volume: 16
• Issue: 11
• Article Number: ARTN 11
• DOI: https://doi.org/10.1186/s12904-016-0179-3
• Keywords: Dying; Diagnosis; Clinical decision making
• Public URL: https://hull-repository.worktribe.com/output/444519
• Publisher URL: http://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-016-0179-3
• Additional Information: Copy of article first published in: BMC palliative care, 2017, v.16, no.11.
• Contract Date: Oct 25, 2016