Exploring preferences for place of death with terminally ill patients: qualitative study of experiences of general practitioners and community nurses in EnglandBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2391 (Published 15 July 2009) Cite this as: BMJ 2009;339:b2391
- Daniel Munday, associate clinical professor in palliative medicine,
- Mila Petrova, research fellow,
- Jeremy Dale, professor of primary care
- 1Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry CV4 7AL
- Correspondence to: D Munday
- Accepted 25 February 2009
Objective To explore the experiences and perceptions of general practitioners and community nurses in discussing preferences for place of death with terminally ill patients.
Design Qualitative study using semistructured interviews and thematic analysis.
Participants 17 general practitioners and 19 nurses (16 district nurses, three clinical nurse specialists).
Setting 15 general practices participating in the Gold Standards Framework for palliative care from three areas in central England with differing socio-geography. Practices were selected on the basis of size and level of adoption of the standards framework.
Results All interviewees bar one had experience of discussing preferred place of death with terminally ill patients. They reported that preferences for place of death frequently changed over time and were often ill defined or poorly formed in patients’ minds. Preferences were often described as being co-created in discussion with the patient or, conversely, inferred by the health professional without direct questioning or receiving a definitive answer from the patient. This inherent uncertainty challenged the practicability, usefulness, and value of recording a definitive preference. The extent to which the assessment of enabling such preferences can be used as a proxy for the effectiveness of palliative care delivery is also limited by this uncertainty. Generally, interviewees did not find discussing preferred place of death an easy area of practice, unless the patient broached the subject or led the discussions.
Conclusions Further research is needed to enable development of appropriate training and support for primary care professionals. Better understanding of the importance of place of death to patients and their carers is also needed.
We thank the participants in the study for their detailed and perceptive responses. We also thank Kashifa Mahmood-Yousuf and Shona Agarwal for doing the interviews; Steven Martin for supporting the work on coding the interviews; and Janice Koistinen for helping to improve the clarity and logic of the text.
Contributors: DM and JD jointly conceived and designed the study. Kashifa Mahmood-Yousuf and Shona Agarwal carried out the interviews. MP analysed the data and developed the interpretative framework. Steven Martin coded part of the interviews independently to compare codes and assignments with those of MP. MP and DM jointly drafted the manuscript. JD and Janice Koistinen contributed to the interpretation and prioritisation of findings, and all authors edited and agreed upon the final manuscript. DM and MP are the guarantors.
Funding: This research was funded by Macmillan Cancer Support. We declare that Macmillan Cancer Support has entrusted our research team to make all decisions associated with collecting, analysing, and interpreting data and presenting findings, and that they have not influenced this process in any way.
Competing interests: DM and JD received a grant from Macmillan Cancer Support to evaluate phases 3-6 of the Gold Standards Framework and are members of the Macmillan Primary Care Research Collaborative. The post of MP has been partially funded by Macmillan Cancer Support.
Ethical approval: Multicentre Research Ethics Committee approval; ref 05/Q2803/48.
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