GPs' decisions about prescribing end-of-life anticipatory medications: a qualitative study.

BACKGROUND: GPs have a central role in decisions about prescribing anticipatory medications to help control symptoms at the end of life. Little is known about GPs' decision-making processes in prescribing anticipatory medications, how they discuss this with patients and families, or the subsequent use of prescribed drugs. AIM: To explore GPs' decision-making processes in the prescribing and use of anticipatory medications for patients at the end of life. DESIGN AND SETTING: A qualitative interview study with GPs working in one English county. METHOD: Semi-structured interviews were conducted with a purposive sample of 13 GPs. Interview transcripts were analysed inductively using thematic analysis. RESULTS: Three themes were constructed from the data: something we can do, getting the timing right, and delegating care while retaining responsibility. Anticipatory medications were a tangible intervention GPs felt they could offer patients approaching death (something we can do). The prescribing of anticipatory medications was recognised as a harbinger of death for patients and their families. Nevertheless, GPs preferred to discuss and prescribe anticipatory medications weeks before death was expected whenever possible (getting the timing right). After prescribing medications, GPs relied on nurses to assess when to administer drugs and keep them updated about their use (delegating care while retaining responsibility). CONCLUSION: GPs view anticipatory medications as key to symptom management for patients at the end of life. The drugs are often presented as a clinical recommendation to ensure patients and families accept the prescription. GPs need regular access to nurses and rely on their skills to administer drugs appropriately. Patients' and families' experiences of anticipatory medications, and their preferences for involvement in decision making, warrant urgent investigation.National Institute for Health Research NIHR School for Primary Care Research. National Institute for Health Research Applied Research Collaboration East of England

Constructing denial as a disease object: accounts by medical students meeting dying patients

As part of the general shift in contemporary healthcare from a focus on specific diseases to treating the whole person, doctors are now expected to be reflective and engage empathetically with patients. Yet, the context of end of life potentially confounds this commitment. Here we draw on the written submissions of UK medical students confronting dying patients to offer insight into a range of entangled issues. Although the exercise is designed to highlight the value of listening to patients and to encourage reflective practice, the experience of ultimately not being able to treat or cure frequently challenges the students’ understanding of the central purpose of clinical care and their future role as doctors. Because they invariably draw on the notion of ‘good death’, whenever they have to make sense of patient behaviour deemed as irrational or obstructive the students employ the concept of ‘denial’ as a strategic category. In this context denial is referred to as a disease-like object that the students feel they can, and should, diagnose and treat. Such conceptual operations consequently illustrate a tension arising from trying to acknowledge the value of a whole-patient approach while simultaneously reproducing the emphasis placed on identifying those discrete elements that determine legitimate medical intervention

GPs' perceptions of advance care planning with frail and older people: a qualitative study.

BACKGROUND: Frail and older people are estimated to account for 40% of deaths. Despite conversations about end-of-life care being an important component of the national End of Life Care Strategy, there is a marked disparity between the majority who would like to discuss advance care plans, and the minority who currently have this opportunity. AIM: To investigate the attitudes of GPs to advance care planning (ACP) discussions with frail and older individuals. DESIGN AND SETTING: Focus group study with GPs in Cambridgeshire between September 2015 and January 2016. METHOD: Five focus groups with 21 GPs were purposively sampled to maximise diversity. Framework analysis was used to analyse transcripts and develop themes. RESULTS: Although some GPs were concerned it might cause distress, the majority felt that raising ACP was important, especially as preparation for future emergencies. Knowing the individuals, introducing the idea as part of ongoing discussions, and public awareness campaigns were all facilitators identified. Several considered that service limitations made it difficult to fulfil patients' wishes and risked raising unrealistic patient expectations. Other barriers identified included uncertainty over prognosis and difficulties ensuring that individuals' wishes were respected. CONCLUSION: Most GPs viewed ACP as important. However, their enthusiasm was tempered by experience. This study highlights the difficulties for GPs of encouraging dialogue and respecting individuals' wishes within the constraints of the existing health and social care system. National publicity campaigns and encouraging patients to prioritise healthcare outcomes could help GPs raise care preferences without causing a detrimental impact on patients or raising unrealistic expectations. Once patients agree their care preferences, they need to be documented, accessible, and reviewed by all relevant health and social care providers to ensure that their wishes are respected, and plans amended as their circumstances change

Planning for an uncertain future in progressive neurological disease: a qualitative study of patient and family decision-making with a focus on eating and drinking

Abstract Background Dysphagia and other eating and drinking difficulties are common in progressive neurological diseases. Mealtimes can become a major source of difficulty and anxiety for patients and their families. Decisions about eating, drinking and care can become challenging as disease progresses, and the person in question loses the capacity to participate in decisions about their own care. We sought to investigate how patients and their family members make decisions about their future care as their condition deteriorates, with a particular focus on mealtimes, eating and drinking. Methods Longitudinal qualitative in-depth interviews were undertaken with patients and their family members (N = 29) across a range of disease groups, including: dementia, Parkinson’s Disease, Huntington’s Disease, Progressive Supranuclear Palsy, Motor Neurone Disease, Multiple Sclerosis. Patients had varying degrees of eating and drinking difficulties, and levels of decision-making capacity. Interviews were ‘participant led’ and undertaken in the patients’ own homes or a place of their choosing. Follow-up interviews were three months to one year later depending upon disease trajectory. Interviews were audio recorded and analysed in NVivo using a Thematic Analysis approach. Results Twenty-nine participants were interviewed between 2015 and 2017. Two key themes emerged from the analysis: 1) Health Literacy: the extent to which patients and relatives appeared to know about the condition and its treatment. Patients and their family members varied in their ability to speak and communicate about their condition and prognosis. 2) Planning style: the extent to which participants appeared to value involvement in advance care-planning. Patients and their family members varied in the way in which they made decisions: some preferred to ‘take each day as it comes’, while others wished to plan extensively for the future. Conclusions Issues with eating and drinking are often overlooked. Clinicians need to understand both the patient’s level of health literacy and their style of planning before communicating with patients and their families about these sensitive issues

A Potential Super-Venus in the Kepler-69 System

Transiting planets have greatly expanded and diversified the exoplanet field. These planets provide greater access to characterization of exoplanet atmospheres and structure. The Kepler mission has been particularly successful in expanding the exoplanet inventory, even to planets smaller than the Earth. The orbital period sensitivity of the Kepler data is now extending into the habitable zones of their host stars, and several planets larger than the Earth have been found to lie therein. Here we examine one such proposed planet, Kepler-69c. We provide new orbital parameters for this planet and an in-depth analysis of the habitable zone. We find that, even under optimistic conditions, this 1.7 R_⊕ planet is unlikely to be within the habitable zone of Kepler-69. Furthermore, the planet receives an incident flux of 1.91 times the solar constant, which is similar to that received by Venus. We thus suggest that this planet is likely a super-Venus rather than a super-Earth in terms of atmospheric properties and habitability, and we propose follow-up observations to disentangle the ambiguity

’Knowing everything and yet nothing about her’: medical students’ reflections on their experience of the dissection room

Anatomy education by cadaveric dissection teaches medical students not only the formal curriculum in human anatomy, but also a ‘hidden curriculum’ whereby they learn the attitudes, identities and behaviours expected of doctors. While dissection has been investigated as a challenge to and training in emotional regulation, little attention has been paid hitherto to the forms of medical knowledge and identity which students encounter and develop in the dissection room. This study analyses a corpus of 119 tributes written by three consecutive cohorts of first-year medical students at a university to their cadaveric donors. We employ a Foucauldian discourse analysis methodology, seeking to elucidate the features of the subject position, the narrative ‘I’ or ‘we’ of the tributes, and the modes of knowledge which operate between that subject position and its object, the donor. We observe that students find themselves in a transitional state between personal and scientific modes of knowledge of the human, which correspond to different models of the subject position occupied by the student. While in many tributes these modes exist in an uneasy disjunction, others employ creative reflection to suggest new modes of knowledge and identity which may inform ethical practice