What are the barriers for senior community nurses in discussing advanced care planning for patients with long term conditions?

Background

In 2008 the Department of Health introduced a national initiative to improve end of life experiences for all those at the end of their lives (Department of Health, 2008). There remains, however, significant variation of the rates of people dying in their preferred place of care depending on both geographical location in the UK and the nature of their illness (Department of Health, 2012). There is evidence to suggest that those dying from long term conditions are less likely to have had the opportunity to develop an advanced care plan to express their end of life care wishes (Gott et al, 2009, Barclay et al 2011). Community nurses work with patients with long term conditions and are theoretically well placed to discuss advanced care plans with their patients (Henry and Hayes 2010.)

Aim

The study aimed to explore barriers for senior community nurses in initiating discussions with patients about end of life care wishes.

Design of the study

Qualitative using semi structured interviews and an interpretive phenomenological approach.

Method

A literature review was conducted to identify possible gaps in knowledge and possible themes for the semi structured interviews. Senior community nurses at band 6 and above were then invited to participate. Four nurses were interviewed and their interviews transcribed, the data was analysed and common themes identified.

Results

Key themes identified were the importance of the human relationship between clinician and patient to establish a trusting relationship so that the possibility of dying and the patient’s wishes could be discussed. The impact of recent and historical events in healthcare (Harold Shipman, negative press coverage of Liverpool Care Pathway, Mid Staffordshire Trust public enquiry) were acknowledged as possible barriers to building trust. The difficulty in identifying patients with long term conditions were deteriorating was also identified. The difficulty in predicting prognosis was seen as a key barrier to initiating end of life discussions.

Conclusion

Emotional labour and prognostic uncertainty made initiating discussions about end of life preferences in this patient group challenging. There was a clear consensus that advanced care planning was beneficial for patients. The need to normalise such discussions so that they become standard care would negate some of the barriers that nurses encounter.