6 End of life care on acute hospital wards: the importance of dialogue and decision making

Background shared decision-making (SDM) has been recommended as the gold standard for decision making in end of life care when decisions may be complex and involve multiple possible courses of action. The perspectives of patients, relatives and staff members about decision making at the end of life on hospital wards have been little researched in reaching this recommendation. This presentation analyses the practice of end of life care decision making on hospital wards from the perspectives of patients, relatives and healthcare staff. Methods data collection comprised ethnographic non-participant observation of 280 hours on two acute hospital wards and 36 semi-structured interviews with staff members, relatives, and patients thought to be approaching the end of life. Data were analysed using a constructivist grounded theory approach. Results decision making is an important part of end of life care. However, this research suggests that decision making per se is not the priority of patients and relatives. Instead, the crucial thing is taking part in discussion and being kept informed by staff members. Ongoing dialogue to establish and maintain a shared understanding between healthcare professionals and those who receive care is often the real priority for patients and relatives. Conclusions discussion between patients, relatives and healthcare professionals must be prioritised in clinical practice. Without shared understanding, gained through ongoing dialogue, shared decision making is impossible. Senior healthcare staff must demonstrate such behaviour to their junior colleagues. An environment that supports ongoing dialogue is also needed. Recommendations for clinical practice and future research will be made.