Challenges and opportunities for improvement when people with an intellectual disability or serious mental illness also need palliative care: A qualitative meta-ethnography

BACKGROUND: People with diagnoses of intellectual disability or serious mental illness have higher mortality rates due to physical comorbidities; better understanding is needed to guide best practice in provision of palliative care for these populations. AIMS: To identify multivoiced perspectives, drawn from lived experience of: what works, and what does not, in palliative care for people with intellectual disability or serious mental illness; challenges in, and opportunities to improve, palliative care. DESIGN: A systematically constructed qualitative meta-ethnography. Protocol published (PROSPERO: CRD42021236616). DATA SOURCES: MEDLINE, PsychINFO, CINAHL PLUS and Embase used without date limitations. Papers published in English, containing qualitative data on palliative care provision for people with a diagnosis of intellectual disability or serious mental illness were included. Global five-point strength score applied for relevance/quality appraisal. RESULTS: Familiarity (of location, people and/or things) is important for good palliative care. Assumptions and misunderstandings about the role of mental capacity assessment to appropriately involve the patient in decision-making are common. Adapting training for palliative care staff to address concerns and beliefs about mental illness is one of the methods that helps avoid diagnostic overshadowing. Proactive identification of service arrangements to meet needs of persons with personality, psychotic, delusional and bipolar affective disorders will help optimise care. CONCLUSIONS: Evidence, including the voices of people with intellectual disability or serious mental illness is urgently needed to guide efforts to improve their access to and experience of palliative care. More evidence is especially needed to understand, develop and implement best practice for people with psychosis, bipolar affective disorder, mania and personality disorder

How well do UK assistantships equip medical students for graduate practice? Think EPAs

The goal of better medical student preparation for clinical practice drives curricular initiatives worldwide. Learning theory underpins Entrustable Professional Activities (EPAs) as a means of safe transition to independent practice. Regulators mandate senior assistantships to improve practice readiness. It is important to know whether meaningful EPAs occur in assistantships, and with what impact. Final year students at one UK medical school kept learning logs and audio-diaries for six one-week periods during a year-long assistantship. Further data were also obtained through interviewing participants when students and after three months as junior doctors. This was combined with data from new doctors from 17 other UK schools. Realist methods explored what worked for whom and why. 32 medical students and 70 junior doctors participated. All assistantship students reported engaging with EPAs but gaps in the types of EPAs undertaken exist, with level of entrustment and frequency of access depending on the context. Engagement is enhanced by integration into the team and shared understanding of what constitutes legitimate activities. Improving the shared understanding between student and supervisor of what constitutes important assistantship activity may result in an increase in the amount and/or quality of EPAs achieved

Multidisciplinary Team Meetings as Care in Practice: an ethnography of hospital and community palliative care in the UK

Background: Palliative care often involves the use of Multidisciplinary Team Meetings (MDTs), aimed at improving quality and continuity of care. Key to these meeting is the communication about complex cases; yet within the meetings, specific problems may go unresolved and categorical decisions may not be made. Therefore, what are the MDTs for and what do they do? Aims: We take the MDTs of two palliative care teams within the same UK NHS (National Health Service) Trust covering acute and community settings as an ethnographic object, to explore what kind of work is done within them and with what effects. We seek to better understand if and how these meetings and teamwork provide care for patients at the end of life. Methods: This paper draws on the analysis of over 60 MDTs, observed as part of a larger ethnographic study about forms of care within palliative care. This research, spanning 17 months since May 2018, consisted of shadowing of staff members, and interviews with staff members and patients. Fieldnotes of the meetings were written up during or after the meeting. Emerging themes were identified through coding and memo-ing the material in NVivo 12, informed by practice theory. Results: The primary practice takes the shape of ‘feeling one’s way’ together through: complex cases; individual and the team members’ needs to continue performing under mounting work and resource pressures; anticipations of future demands of measuring the work the team provides. While acknowledged and appreciated by all team members as a central part of their daily work, this MDT work is not readily captured as a visible form of patient care, both from patient and carer perspectives, nor from resource planning measures that determine the staff levels. Discussion: We argue that there is a need to appreciate and articulate this work as care for different and shifting set of recipients: the patient, the individual team members, the team process, and the meeting itself

The ‘Dunblane massacre’ as a ‘photosensitive plate’

This article seeks to understand the mass murders that took place at Dunblane in 1996 and to consider if we might see aspects of this mass shooting as prophetic of other mass murders, such as those that took place at Columbine, Sandy Hook and on Utoya Island. It does this by using what we describe as a ‘criminological autopsy’ about the shootings and, in doing so, considers why this mass murder – still the worst in British history – has rarely been considered within criminology

Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents.

BACKGROUND: Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population. AIM: To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care. DESIGN: A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms. SETTING AND PARTICIPANTS: Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014. RESULTS: A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcare-associated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death. CONCLUSION: Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk

Exploring weight loss services in primary care and staff views on using a web-based programme

Although primary care staff felt they should deliver weight loss services, low levels of faith in the efficacy of current treatments resulted in provision of under-resourced and 'ad hoc' services. Integration of a web-based weight loss programme that promotes service evaluation and provides a cost-effective option for supporting patients may encourage practices to invest more in weight management service