The study protocol of: 'Initiating end of life care in stroke: clinical decision-making around prognosis'.

Journal article


Burton, C., Payne, S., Turner, M., Bucknall, T., Rycroft-Malone, J., Tyrell, P., Horne, M., Ntambwe, L.I., Tyson, S., Mitchell, H., Williams, S. and Elghenzai, S. 2014. The study protocol of: 'Initiating end of life care in stroke: clinical decision-making around prognosis'. BMC Palliative Care. 13 (55).
AuthorsBurton, C., Payne, S., Turner, M., Bucknall, T., Rycroft-Malone, J., Tyrell, P., Horne, M., Ntambwe, L.I., Tyson, S., Mitchell, H., Williams, S. and Elghenzai, S.
Abstract

Background: The initiation of end of life care in an acute stroke context should be focused on those patients and families with greatest need. This requires clinicians to synthesise information on prognosis, patterns (trajectories) of dying and patient and family preferences. Within acute stroke, prognostic models are available to identify risks of dying, but variability in dying trajectories makes it difficult for clinicians to know when to commence palliative interventions. This study aims to investigate clinicians’ use of different types of evidence in decisions to initiate end of life care within trajectories typical of the acute stroke population.

Methods/design: This two-phase, mixed methods study comprises investigation of dying trajectories in acute
stroke (Phase 1), and the use of clinical scenarios to investigate clinical decision-making in the initiation of palliative care (Phase 2). It will be conducted in four acute stroke services in North Wales and North West England. Patient and public involvement is integral to this research, with service users involved at each stage.

Discussion: This study will be the first to examine whether patterns of dying reported in other diagnostic groups are transferable to acute stroke care. The strengths and limitations of the study will be considered. This research will produce comprehensive understanding of the nature of clinical decision-making around end of life care in an acute stroke context, which in turn will inform the development of interventions to further build staff knowledge, skills
and confidence in this challenging aspect of acute stroke care.

KeywordsAcute stroke; Palliative care; End of life care; Decision making; Dying trajectories; Implementation
Year2014
JournalBMC Palliative Care
Journal citation13 (55)
PublisherBioMed Central Ltd
ISSN1472-684X
Digital Object Identifier (DOI)doi:10.1186/1472-684X-13-55
Official URLhttps://doi.org/10.1186/1472-684X-13-55
Publication dates
Print05 Dec 2014
Publication process dates
Accepted27 Nov 2014
Deposited15 Jun 2020
References

1. Royal College of Physicians: National Sentinel Stroke Clinical Audit 2010
Round 7. London: 2011.
2. Department of Health: National Stroke Strategy. London: 2007.
3. Stevens T, Payne SA, Burton C, Addington-Hall J, Jones A: Palliative care in
stroke: a critical review of the literature. Palliat Med 2007, 21:323–331.
4. Burton CR, Payne S, Addington-Hall J, Jones A: The palliative care needs of
acute stroke patients: a prospective study of hospital admissions.
Age Ageing 2010, 39(5):554–559.
5. Counsell C, Dennis M: Systematic review of prognostic models in patients
with acute stroke. Cerebrovasc Dis 2001, 12(3):159–170.
6. Payne S, Burton C, Addington-Hall J, Jones A: End-of-life issues in acute
stroke care: a qualitative study of the experiences and preferences of
patients and families. Palliat Med 2010, 24(2):146–153.
7. Seymour J, Witherspoon R, Gott M, Ross H, Payne S: Dying in Older Age:
End-of-Life Care. Bristol: Policy Press; 2005.
8. Glare P, Christakis NA: Overview: Advancing the Clinical Science of
Prognostication. In Prognosis in Advanced Cancer. Edited by Glare P,
Christakis NA. Oxford: Oxford University Press; 2008:3–12.
9. Lunney JR, Lynn J, Hogan C: Profiles of older medicare decedents. J Am
Geriatr Soc 2002, 50:1108–1112.
10. Gott M, Barnes S, Parker C, Payne S, Seamark D, Gariballa S, Small N: Dying
trajectories in heart failure. Palliat Med 2007, 21:95–99.
11. Lynn J, Adamson DM: Living Well at the End of Life. Adapting Health Care to
Serious Chronic Illness in Old Age. Washington: Rand Health; 2003.
12. Glaser BG, Strauss AL: Awareness of Dying. New York: Aldine; 1965.
13. Gott M, Small N, Barnes S, Payne S, Seamark D: Older people’s views of a
good death in heart failure: Implications for palliative care provision.
Soc Sci Med 2008, 67(7):1113–1121.
14. Payne S, Froggatt K, O’Shea E, Murphy K, Larkin P, Casey D, Léime A:
Improving palliative and end-of-life care for older people in Ireland:
a new model and framework for institutional care. J Palliat Care 2009,
25(3):218–226.
15. General Medical Council: Treatment and Care Towards the end of Life: Good
Practice in Decision Making. London: 2007.
16. Department of Health: Equity and Excellence: Liberating the NHS. London: 2010.
17. Burton C, Payne S: Integrating palliative care within acute stroke services:
developing a programme theory of patient and family needs,
preferences and staff perspectives. BMC Palliat Care 2012, 11(1):22–30.
18. National Institute for Health and Clinical Excellence: Diagnosis and Initial
Management of Acute Stroke and Transient Ischaemic Attack (TIA). London: 2008.
19. Lerdal A, Bakken LN, Kouwenhoven SE, Pedersen G, Kirkevold M, Finset A,
Kim HS: Post-stroke fatigue – a review. J Pain Symptom Manag 2009,
38(6):928–949.
20. Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B, Titchen A: An
exploration of the factors that influence the implementation of evidence
into practice. J Clin Nurs 2004, 13:913–924.
21. Bamford J, Sandercock P, Dennis M, Warlow C, Burn J: Classification and
natural history of clinically identifiable subtypes of cerebral infarction.
Lancet 1991, 337(8756):1521–1526.
22. Bucknall TK: A gaze through the lens of decision theory towards
knowledge translation science. Nurs Res 2007, 56(Suppl 4):60–66.
23. Downie R, Macnaughton J: Clinical Judgement. Oxford: Oxford University
Press; 2000.
24. Hogarth RM: Judgement and Choice: The Psychology of Decision. Chichester:
Wiley; 1980.
25. Roberts SE, Goldacre MJ: Case fatality rates after hospital admission for
stroke. BMJ 2003, 326:193–194.
26. Murtagh FEM, Preston M, Higginson I: Patterns of dying: palliative care for
non-malignant disease. Clin Med 2004, 4:39–44.
27. Glaser B, Strauss AL: A Time for Dying. Chicago: Aldine Publishing; 1968.
28. Mental Capacity Act; 2005 [http://www.legislation.gov.uk/ukpga/2005/9/
contents]
29. National Bereavement Survey: National Bereavement Survey; [http://www.
ons.gov.uk/ons/rel/subnational-health1/national-survey-of-bereaved-people–
voices-/2013/index.html]
30. Fleiss JL: Measuring nominal scale agreement among many raters.
Psychol Bull 1971, 76(5):378.
31. Miles MB, Huberman AM: Qualitative Data Analysis: An Expanded Sourcebook.
Thousand Oaks (CA): Sage Publications; 1994.
32. Bucknall TK, Aitken LM: Think Aloud Technique. In The Research Process in
Nursing. 6th edition. Edited by Gerrish K, Lacey A. Oxford: Wiley Blackwell;
2009:395–405.
33. Thompson C, Dowding D: Clinical Decision Making and Judgement in
Nursing. London: Churchill Livingstone; 2001.
34. Fonteyn ME, Kuipers B, Grobe SJ: A description of think aloud method
and protocol analysis. Qual Health Res 1993, 3:430–441.
35. Skanér Y, Strender L-E, Bring J: How do GPs use clinical information in their
judgements of heart failure? Scand J Prim Health Care 1998, 16:95–100.
36. Lamond D, Crow R, Chase J: Judgements and processes in care decisions
in acute medical and surgical wards. J Eval Clin Pract 1996, 2:211–216.
37. Ritchie J, Spencer L: Qualitative Data Analysis for Applied Policy Research.
In Analysing Qualitative Data. Edited by Bryman A, Burgess R. London:
Routledge; 1994.
38. Pope C, Ziebland S, Mays N: Analysing Qualitative Data. In Qualitative
Research in Health Care. 3rd edition. Edited by Pope C, Mays N. Oxford:
Blackwell; 2006:63–81.
39. Hudson P, Aranda S, Kristjanson L, Quinn K: Minimising gate-keeping in
palliative care research. Eur J Palliat Care 2005, 12(4):165–169.

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