Open communication strategies between a triad of ‘experts’ facilitates death in usual place of residence: A realist evaluation

Abstract

Background: In order to meet policy drivers on death in usual place of residence, it is key to understand how shared decision-making can be facilitated in practice. An integrated care pathway was implemented in primary care in the North East of England to facilitate death in usual place of residence. Aim: To understand how, for whom and in which circumstances death in usual place of residence is facilitated. Design: A mixed method realist evaluation was employed. Local primary care practice death audit data were analysed to identify outcomes using a mixed effects logistic regression model. Focus groups and interviews with staff of the integrated care pathway and bereaved relatives were analysed to identify the related contexts and mechanisms. Setting/participants: Death audit data of 4182 patients were readily available from 14 general practitioner practices. Three focus groups were conducted with primary and secondary care staff, voluntary sector organisations and care home representatives. Interviews with bereaved relatives were carried out in participants’ homes ( n = 5). Results: A mixed effects logistic regression model indicated a significant effect of year on death in usual place of residence when compared to a model without year using an analysis of deviance ( p = 0.016). Qualitative analysis suggested that this outcome was achieved when a triad of ‘experts’ (comprising patient, family members/family carers/formal carers and healthcare professionals) used open communication strategies. Conclusion: An empirically supported theory of how, for whom and in which circumstances death in usual place of residence happens is provided, which has important implications for both policy and practice.

A critical exploration of professional jurisdictions and role boundaries in inter-professional end-of-life care in the community

“…Further, paramedics' discomfort with attending end-of-life calls was compounded by concerns that patients' preferences to die at home, conflicted with their standard approach of transferring patients to hospital, causing uncertainty around the best course of action with fear of legal repercussions. Paramedics' fear of litigation following a failure to act, or being seen to act has been reported previously (Hoare et al, 2018, Kirk et al, 2017b, Dalkin et al, 2018, Patterson et al, 2019. Professional jurisdictions are shaped and constrained by legalities.…”

Namaste care in the home setting: developing initial realist explanatory theories and uncovering unintended outcomes

“…CMO configurations are used as explanatory formulae (otherwise referred to as realist programme theories), which are developed and refined with empirical data. As with other evaluations of person-centred interventions,33 the use of a realist approach will help to expose the multiple resources delivered as part of NC, the ways that these may be employed with different people, in diverse situations and how these generate outcomes. Applying the principles of realist evaluation therefore will determine why NC is successful or unsuccessful, in particular contexts.…”

Engaging family caregivers and health system partners in exploring how multi-level contexts in primary care practices affect case management functions and outcomes of patients and family caregivers at end of life: a realist synthesis

“…Patients and families may be better prepared for end-of-life events and bereavement [48,50,52,75,81], and health systems are less likely to use aggressive life-sustaining medical interventions before a patient's time of death [52,82], have lower rates of inhospital deaths [64], and decreased health care costs [63]. In addition to practitioner-patient conversations and planning, it is important that end-of-life plans are clearly communicated across health and social sectors involved in implementing the patients' care plan [63,70,83]. Intersectoral communication was not explored in this review, but it is an important element that enables links to community resources and improved outcomes.…”

“…The literature demonstrated the benefits of families being involved in end-of-life planning. Better communication between PCPs and families helps increase family members’ confidence around caring for patients in their usual place of residence [ 84 ]. Despite this benefit, it is important to recognize that families may not be prepared for, or desire to, care for the end-of-life patient at home [ 85 ].…”