Existential Communication and Leadership

The aim of this article is to introduce and explain a number of important existentialist philosophers and concepts that we believe can contribute to a critical approach to leadership theory. Emphasis is placed on understanding the nature of communication from an existentialist perspective and so Jaspers' conceptualization of existential communication is introduced along with important related concepts that may be regarded as important facets of leader communication including Being-in-the-world, the Other, intersubjectivity, dialogue and indirect communication. Particular attention is paid to Buber's ideas on communication as relationship and dialogue. Throughout, reference is made to contemporary, and what is often regarded as orthodox, thinking regarding the centrality of communication to leadership practice as a means by which to highlight the salience of an existentialist analysis

Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life

Background: Advance care planning (ACP) enables patients to consider, discuss and, if they wish, document their wishes and preferences for future care, including decisions to refuse treatment, in the event that they lose capacity to make decisions for themselves. ACP is a key component of UK health policy to improve the experience of death and dying for patients and their families. There is limited evidence about how patients and health professionals understand ACP, or when and how this is initiated. It is evident that many people find discussion of and planning for end of life care difficult, and tend to avoid the topic. Aim: To investigate how patients, their relatives and health professionals initiate and experience discussion of ACP and the outcomes of advance discussions in shaping care at the end of life. Design and data collection: Qualitative study with two workstreams: (1) interviews with 37 health professionals (general practitioners, specialist nurses and community nurses) about their experiences of ACP; and (2) longitudinal case studies of 21 patients with 6-month follow-up. Cases included a patient and, where possible, a nominated key relative and/or health professional as well as a review of medical records. Complete case triads were obtained for 11 patients. Four cases comprised the patient alone, where respondents were unable or unwilling to nominate either a family member or a professional carer they wished to include in the study. Patients were identified as likely to be within the last 6 months of life. Ninety-seven interviews were completed in total. Setting: General practices and community care settings in the East Midlands of England. Findings: The study found ACP to be uncommon and focused primarily on specific documented tasks involving decisions about preferred place of death and cardiopulmonary resuscitation, supporting earlier research. There was no evidence of ACP in nearly half (9 of 21) of patient cases. Professionals reported ACP discussions to be challenging. It was difficult to recognise when patients had entered the last year of life, or to identify their readiness to consider future planning. Patients often did not wish to do so before they had become gravely ill. Consequently, ACP discussions tended to be reactive, rather than pre-emptive, occurring in response to critical events or evidence of marked deterioration. ACP discussions intersected two parallel strands of planning: professional organisation and co-ordination of care; and the practical and emotional preparatory work that patients and families undertook to prepare themselves for death. Reference to ACP as a means of guiding decisions for patients who had lost capacity was rare. Conclusions: Advance care planning remains uncommon, is often limited to documentation of a few key decisions, is reported to be challenging by many health professionals, is not welcomed by a substantial number of patients and tends to be postponed until death is clearly imminent. Current implementation largely ignores the purpose of ACP as a means of extending personal autonomy in the event of lost capacity. Future work: Attention should be paid to public attitudes to death and dying (including those of culturally diverse and ethnic minority groups), place of death, resuscitation and the value of anticipatory planning. In addition the experiences and needs of two under-researched groups should be explored: the frail elderly, including those who manage complex comorbid conditions, unrecognised as vulnerable cases; and those patients affected by stigmatised conditions, such as substance abuse or serious mental illness who fail to engage constructively with services and are not recognised as suitable referrals for palliative and end of life care. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Stroke and Palliative Care

Meeting the palliative care needs of stroke patients requires stroke specialists to develop enhanced knowledge and skills in palliation in order to address the specific challenges that stroke presents. This requires investment from within the stroke field and a commitment to a more holistic approach to care which extends beyond rehabilitation goals. This chapter identifies a range of challenges in delivering palliative care for stroke patients. It considers generic palliative care pathways and tools, and their suitability in the context of stroke. The chapter presents case studies which illustrate how some of these care pathways and tools could be used with stroke patients. It discusses three palliative care approaches: the Liverpool Care Pathway; the Gold Standards Framework; and the Assessment, Management, Best practice, Engagement, and Recovery care bundle. The chapter concludes with recommendations to guide the development of improved palliative care in stroke

Context of care and service delivery

This chapter explores some of the current political, economic and social policies that are shaping the context of nursing practice and service delivery for children and young people with long‐term illnesses. Examples of service models and nursing roles are used, demonstrating their influence upon the shifting boundaries of clinical practice and service delivery. The chapter also explores the complexities surrounding shifting health and social care workforce role boundaries, associated competencies and their impact upon service users, professionals and managers. There have been changes to the mechanisms for funding and commissioning health care services to encourage more integrated local needs‐based commissioning and increasing accountability and governance of health care expenditure. The chapter considers some of the implications of the political, social and economic drivers upon service from a practice context. It highlights the impact on the roles of parents and nurses, and service challenges that need to be addressed to support these changes