Advance care planning: between tools and relational end-of-life care?

The way in which end-of-life care is delivered in the UK has changed dramatically over the last few years. Owing to the changes in systems and care practice promoted in the End of Life Care Strategy more people have access to higher quality care, including advance care planning and symptom management. Drawing on the ‘best practice’ at the time, the Strategy recommended the use of several tools to facilitate identifying dying patients, communicating and planning future care, and coordinating otherwise disparate services. These changes have not gone unnoticed: in 2010, the UK was considered as the best place to die by the Economist Intelligence Unit, and recent UK data released as part of Dying Matters Awareness week suggest people are more comfortable talking about death and dying now than they were 10 years ago. Yet, end-of-life care has been described as ‘failing’, in a 2015 Parliamentary and Health Service Ombudsman's report, particularly in terms of discussing dying and documenting patient preferences

End-of-life care decisions for haemodialysis patients - ‘We only tend to have that discussion with them when they start deteriorating’

Background Haemodialysis patients receive very little involvement in their end-of-life care decisions. Issues relating to death and dying are commonly avoided until late in their illness. This study aimed to explore the experiences and perceptions of doctors and nurses in nephrology for involving haemodialysis patients in end-of-life care decisions. Methods A semi-structured qualitative interview study with 15 doctors and five nurses and thematic analysis of their accounts was conducted. The setting was a large teaching hospital in Wales, UK. Results Prognosis is not routinely discussed with patients, in part due to a difficulty in estimation and the belief that patients do not want or need this information. Advance care planning is rarely carried out, and end-of-life care discussions are seldom initiated prior to patient deterioration. There is variability in end-of-life practices amongst nephrologists; some patients are felt to be withdrawn from dialysis too late. Furthermore, the possibility and implications of withdrawal are not commonly discussed with well patients. Critical barriers hindering better end-of-life care involvement for these patients are outlined. Conclusions The study provides insights into the complexity of end-of-life conversations and the barriers to achieving better end-of-life communication practices. The results identify opportunities for improving the lives and deaths of haemodialysis patients