Successive “National Care of the Dying Audit for Hospitals” record that Health Care Professionals (HCPs), are recognising that patients are dying only days before their death, reducing opportunities for patient involvement in decision-making. This PhD, utilizing a mixed and iterative methodology, addresses how senior HCPs in one hospital recognise dying, and negotiate decision-making with patients and families in this process. In Study One thirteen senior HCPS undertook a Critical Incident Review. These involved the ward based senior HCP who identified dying, and the Hospital Palliative Care Team (HPCT) HCP(s) subsequently involved in the patient’s care. Interviews were recorded, transcribed and themed. In Study Two senior HCPs across the hospital were invited to four consecutive Participatory Action Research (PAR) workshops to critically reflect on the themed data from Study One. Ten HCPs took part (three HPCT HCPs were involved in both studies). The workshops were similarly recorded, transcribed and themed.The themed analysis yielded a model for decision-making but did not explain why dying was identified so late. A psychoanalytically informed psychosocial approach was taken to examine anomalies and contradictions in the data that pointed to less conscious undercurrents in the personal, professional, educational and institutional dynamics involved in the care of patients who are dying. Through this analysis, it is clear that identifying dying, and negotiating decision-making with the patient and their family at this time, is extremely anxiety provoking. Individual and social psychological defence mechanisms that avoid the recognition of dying come into play. HCPs’ experience of learning to care for the dying patient and their family is “chaotic” and anxiety provoking and leaves them ill-equipped. Complicating matters, at the point of recognition of dying, the institution devolves its responsibility for care (requirement for space and time for patient and family conversations, and emotional support for HCPs who sometimes have to deal with angry families) to individual HCPs. The argument is put forward that the HPCT have become part of modern NHS social defence mechanisms. Sensitively facilitated PAR workshops allow interested HCPs to mutually consider how to identify dying earlier; implications of this for the patient, family and themselves; the organisational resources available; and the role of education. Attention is paid to the HCPs emotional experience and psychological defences, and over time there is opportunity to negotiate sustainable practice change.
|Date of Award||2 Oct 2017|
|Supervisor||Paula Smith (Supervisor), Helen Lucey (Supervisor) & Charlotte Dack (Supervisor)|