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Discussing preferred place of death with patients: staff experiences in a UK specialist palliative care setting Anna Fields, Anne Finucane, David Oxenham

S Anna Fields is Medical Student, The University of Edinburgh, College of Medicine and Veterinary Medicine, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland; Anne M Finucane is Research Facilitator and David Oxenham is Medical Director, Marie Curie Hospice Edinburgh, Frogston Road West, Edinburgh, Scotland Correspondence to: Anna Fields [email protected]

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trong taboos against talking about death exist in many countries, including the UK (Department of Health (DH), 2008; Economist Intelligence Unit, 2010). Despite this, end-of-life care strategies in Scotland and England emphasise the importance of facilitating patients to express their preferences about place of death (PPD) and the importance of communicating and realising these preferences where possible (DH, 2008; Scottish Government, 2008). Prospective and retrospective studies exploring PPD indicate that most people wish to die at home (Higginson and Sen-Gupta, 2000; Gomes et al, 2011). However, preferences may change over time and so regular review is required (Townsend et al, 1990; Hinton, 1994; Leonard and Kreeger, 2000; Agar et al, 2008). Facilitating a patient to die in their place of choice requires consideration of a number of

Aim This study aimed to explore staff members’ subjective experiences of discussing PPD with patients in a specialist palliative care service. The intention was to inform clinical practice by providing a greater understanding of staff attitudes and beliefs surrounding PPD discussions.

Method Interpretative phenomenological analysis (IPA) is an inductive approach applicable to a broad range of research topics (Broki and Wearden, 2006). It is grounded in participant data and aims to capture and explore the lived experiences of a relatively small, homogeneous sample (Smith et al, 1999) without testing any pre­ determined hypotheses (Reid et al, 2005). This methodology was used in the present study to explore how staff make sense of their own

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Abstract

Background: National end-of-life care policies propose that health professionals regularly discuss matters such as preferred place of death (PPD) with patients. Aim: To explore clinician experiences of discussing PPD with palliative care patients. Method: Six clinicians from a Scottish hospice each participated in a semi-structured interview. Interview data was analysed using interpretative phenomenological analysis. Results: Four themes were integral to the participants’ accounts: the importance of discussing preferences at the end of life (staff recognise the value of discussing patients’ final wishes), identifying how and when to discuss PPD (discussions are tailored to the individual), reflecting on the emotional aspects of discussing PPD (discussing PPD is challenging but rewarding), and a journey from expectations to experience (discussing PPD becomes easier with time). Conclusion: Although potentially difficult, the participants believed that advance care planning is important and beneficial. With time, they had developed communication strategies enabling them to discuss PPD in an effective, patient-centred way. Key words: Preferred place of death l Preferred place of care l Anticipatory care planning l Hospice l Specialist palliative care l Staff experience l End-of-life choices

factors that may vary with time and context. These include the patient’s illness, beliefs, and wishes, and the available care and support (Gomes and Higginson, 2006). Patients are more likely to die at home if they have previously voiced a wish to do so (Karlsen and AddingtonHall, 1998; Cantwell et al, 2000; Brazil et al, 2002; Gomes and Higginson, 2006). This emphasises the importance of exploring preferences through sensitive discussion as part of ongoing anticipatory care planning. Although it is widely agreed that health professionals should have open end-of-life discussions with patients (Barclay and Maher, 2010), the extent to which individual patients wish to confront these issues varies (Leydon et al, 2000; Clayton et al, 2005; Munday et al, 2007). Furthermore, there are differing views as to when and by whom conversations should be initiated (Clayton et al, 2005). Despite the important role that staff have in achieving patient autonomy, little is known about their experiences of undertaking end-of-life discussions (Munday et al, 2007).

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experiences of discussing PPD, focusing on the themes that the participants raised as being important to them.

Staff member

Gender

Experience of discussing PPD (years)

Staff nurse

Female

More than 10

Marie Curie Hospice Edinburgh provides specialist palliative care services to a population of 500 000. To enable more patients to die in their place of choice, staff members have regular end-of-life conversations with patients wishing to discuss these issues. Each patient’s PPD, or reason why this is unknown, is documented in a standardised form held in their notes and is regularly reviewed.

Community nurse specialist

Female

More than 10

Community nurse specialist

Male

More than 5

Specialist palliative care consultant

Female

Between 1 and 5

Day services nurse

Female

Between 1 and 5

Foundation year 2 doctor

Male

Less than 1

Participants

Question area

Example probes

What are your feelings on discussing PPD with patients?

What do you think about PPD as a topic of discussion?

Tell me about how you

How do discussions come about? What helps you to

discuss PPD

bring up a PPD discussion? How do you prepare?

Tell me a bit about your experiences of talking to patients about PPD

How does it make you feel? Can you describe an ideal discussion? What effect does talking about PPD have on your relationship with the patient?

Context

Six staff members with different levels of experience were purposively recruited (Table 1). Participants were informed about the aims of the study and gave written consent prior to their interview. Participants were selected by the first and second authors. The specialties of the staff members required for interview was agreed beforehand and staff from these areas of the hospice were then invited by the first author (AF) to participate based on their level of experience and availability.

Semi-structured interviews An audio-recorded, face-to-face interview lasting 30–50 minutes was carried out with each participant in a private room at the hospice. The interview approach was flexible and nondirective and aimed to elucidate meaningful, participant-derived accounts. Three broad question areas were covered and probes were used to encourage participants to expand on certain areas (Table 2). All interviews were conducted by the first author.

Data analysis

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Table 1. Sample characteristics

Data analysis was carried out by the lead researcher. The interview recordings were transcribed verbatim and the transcripts then analysed using IPA (Smith et al, 2009). Each transcript was read while listening to the audiorecording. Significant information was underlined and the transcript margin used to note initial interpretations, followed by descriptive, linguistic, and conceptual comments. The next stage involved identifying emergent themes, which conceptualise important areas identified during the initial analysis. Through clustering related emergent themes, superordinate themes were identified. A document of superordinate and sub- (emergent) themes was created with verbatim examples for each account. Taking care not

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PPD, preferred place of death

Table 2. Interview guide

PPD, preferred place of death

to generalise the findings, patterns across accounts were explored. Four master themes were identified by grouping together the key themes from each participant.

Ethical considerations Approval to conduct the study was obtained from the University of Edinburgh Research Ethics Committee and from the Marie Curie Hospice Edinburgh Research Governance Group. Participants were informed that the interview transcripts would be read by the other two researchers who worked at the hospice but that possible identifying information would be removed from these transcripts and from any excerpts used in the report by the first author.

Reflexivity and validity Phenomenological analysis requires that understanding of lived experience is gained through the researcher’s interpretation of the participant’s account. It is essential that researchers demonstrate reflexivity to allow generation of findings that are participant-driven. The lead researcher scrutinised how her role as a medical student may have influenced the data gathered and its interpretation. Credibility checks are important for improving validity in qualitative research (Elliot et al, 1999). To ensure that data interpretations were plausible, a validation check was carried out between

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Table 3. Summary of key themes Theme

Subthemes

Clinical implications

Psychological benefits for patients at a time when they have less control. Enables rounded approach to patient care. Facilitates development of trust and rapport. Responsibility of clinician to give patient the chance to discuss preferences

PPD should be discussed with patients receiving specialist palliative care where possible as it increases their sense of control, enhances trust and rapport between the patient and clinician, and contributes to holistic care

discuss PPD

Discussions are dependent on context and may be easier in the hospice than the home. Early discussions are advantageous for patient and family. Staff tailor discussions to individual patients by identifying verbal and non-verbal cues from their interaction. Discussions can be situated over time. Patient happiness is more important than obtaining information on PPD. A strong staff–patient bond is a prerequisite for PPD discussions

Staff should initiate discussions early on with patients but tailor discussions to the individual, respecting a patient’s wish not to discuss PPD at any time

PPD discussions have challenging aspects

Discussing end-of-life issues challenges health professionals’ role in making patients happy. Other health professionals may delegate advance care planning to palliative care staff. A patient’s PPD may not be feasible—need to negotiate a solution. Importance of overcoming own emotions, e.g. fear of patient distress. A need to use clear, non-euphemistic language. Empathy is a valuable staff quality. Staff support each other. Appreciation of the importance of discussing PPD makes it easier

Importance of staff support network. Need for more training in general medical setting. Communication with family, community teams etc

Discussions become easier with experience

Acceptance that patients may become upset. Development of techniques, e.g. a focus on positive aspects of exploring PPD, phrases to initiate discussions. Learning from team members. Formalising pre-existing skills into a structure

Value of staff shadowing programme

Staff view PPD discussions as important

Staff reflect on how and when to

PPD, preferred place of death

the lead researcher and two participants. This involved discussing the main themes and how they were identified from the transcripts as well as focusing on whether interpretations were correct and whether any master themes should be changed or added.

‘It allows us to provide more holistic care to patients because it’s not just encompassing their symptom management or their psychological support, it’s also where they want to be at the end … so I think it allows us to fit that final bit of the jigsaw.’ (Interview 2)

Results

If managed well, end-of-life discussions can facilitate the development of trust and rapport between staff and patients. Although staff recognise that PPD may change or might not be achievable, discussing PPD is seen as improving care for patients by opening up communication with families, primary care, and other services:

Theme 1: The importance of discussing preferences at the end of life The participants appreciated the importance of discussing PPD as part of anticipatory care planning. The opportunity to discuss choices at the end of life can have psychological benefits for patients, in a situation where they might have lost all sense of self-determination: ‘A lot of patients have this sense that there’s so much loss of control … this gives them an opportunity to discuss … is there perhaps some choice or control about where you want to be during, at the end of life.’ (Interview 4)

The introduction of PPD discussions was also thought to enable a more rounded approach to the patient’s end-of-life experience:

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‘It’s just knowing where people want to die so you can assess … is it a case of equipment, is it a case of care package and em overnight services em and family support. It’s a case of trying to get things arranged in advance to try and …make things, things possible at the end of life.’ (Interview 4)

The participants reported going to great lengths to meet their patients’ final wishes. They said that not attempting to discuss PPD was associated with feelings of having failed the patient, and they viewed addressing the ‘elephant in the room’ as being their responsibility unless the patient openly expressed a wish to talk about such topics:

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Four key themes emerged during the analysis phase. They are summarised in Table 3 and are covered separately below.

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‘If I didn’t try to identify preferred place of death, or preferred place of care, I would feel I’ve let that patient down cos I see it as a huge part of my role.’ (Interview 6)

Theme 2: Identifying when and how to discuss PPD Initiation of end-of-life care discussions was seen as depending on the context and how prepared patients are to confront such topics: ‘When you’re at [the] home you’re in the patient’s territory so it is more difficult, so here [at the hospice] they do expect it, they’re in the hospice … it’s a natural progression that you’re gonna discuss these things …’ (Interview 5)

This suggests that patients at the hospice may have greater awareness of the proximity of death and thus anticipate end-of-life conversations, perhaps making them easier to broach. One participant questioned the optimal time to initiate discussions, feeling that approaching sensitive issues too soon might contradict the supportive aspect of palliative care. This perhaps reflects a fear of being perceived as uncaring, a need for more training and experience in the role, or differences between palliative care in the hospice and patients’ homes: ‘I’ve gone through a phase of it’s not right … to pitch up on the first visit to say, “Where do you want to die?”… Maybe that’s the only thing that they’ve heard in the whole conversation … And then other times I thought well actually if their condition deteriorated, would I know what they wanted and be able to advocate for them?’ (Interview 3)

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However, most participants reported feeling that, as patients have been referred for specialist palliative care, discussions are rarely too early. The distress that might be caused by asking a patient too soon was weighed against the advantages to the patient and their family of a peaceful death in the place of their choice: ‘… when people can die with all the support, with all the medicines, without any added stress, it’s well worth it, so you’ve got to balance it out from that.’ (Interview 5)

Furthermore, to ensure that discussions occurred at a time and pace suitable for the individual patient, the participants reported exploring patients’ understanding of their illness and

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identifying both verbal and non-verbal cues from the interaction: ‘We generally take our cues initially from the admission process where, you know, it’s open questions [like] “Can you tell us a bit about what’s brought you into the hospice?” … and you pick up cues from some of the questions that we ask, just what their understanding is, how much they want to discuss things …’ (Interview 2)

The participants recognised that discussions usually evolve over time, as the majority of patients are eventually open to discussing PPD. A number of reasons why a patient may not wish to discuss PPD were identified, e.g. denial or uncertainty about the future. Being unable to elicit PPD was not viewed as a failure of the staff member or patient, as knowing that a patient does not want to discuss PPD at that time provides more clarity than if the topic had not been broached. The participants reported that patients are assured they can revisit the conversation at any time. The participants viewed the overall aim of discussing PPD as being to ‘maximise patient happiness and comfort’. Thus, maintaining a good relationship with the patient and minimising patient distress are more important than obtaining information. As such, discussions are tailored to the individual, with awareness that patients vary in their level of acceptance of their situation and psychological state:

❛Initiation of end-of-life care discussions was seen as depending on the context and how prepared patients are to confront such topics ...❜

‘I still have to be careful that I’m no[t] pushing somebody too far ahead … even though they’ve got a terminal illness they still need a level of hope … something to look forward to … you cannae make somebody ready or force stuff … they’ve got to be in the right place … on the right page … to start having that kind of discussion.’ (Interview 6)

Having a strong bond with patients was recognised as a prerequisite for discussing PPD and as enabling patients to be more open. The participants commented that patients sometimes change their PPD to the hospice once they develop rapport with staff.

Theme 3: Reflecting on the emotional aspects of discussing PPD Addressing end-of-life issues was depicted as having challenging elements for both health professionals and patients. Although a key responsibility of palliative care staff is to discuss

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end-of-life matters, dealing with patient distress can be difficult, particularly as it may challenge their normal role: ‘Doctors tend to try and make people happy … you don’t want to make people cry.’ (Interview 1)

It was reported that at times the hospice staff feel they are the bearers of bad news in situations where other health professionals have neglected to give patients any warning: ‘… you just feel like nurse death at times, you think God if somebody had just said this is gonna happen so we’ve got a wee bit of an idea and you’re not the one that’s going in and being all doom and gloom. It’s quite difficult.’ (Interview 5)

The unpredictability of events at the end of life was said to add an extra dimension to discussions. One participant said that asking patients where they want to die was potentially ‘opening a can of worms’. As well as alerting patients to the fact that they are going to die, with all the associated emotions, it raises issues such as whether or not their wishes are achievable: ‘When you have a feeling that there’s sort of, difference of opinion between perhaps the patient and, and their relatives or their carers, or if, if you know that it’s just not gonna be feasible, that’s, that’s when it feels a bit more difficult cos then you’re needing to support the patient with the fact that it may not be possible.’ (Interview 4)

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it’s whether you’re brave enough to pick them up.’ (Interview 5)

Furthermore, although avoiding use of the words ‘death’ and ‘dying’ seems less threatening, the participants described the need to use clear language when discussing PPD: ‘If you talk about it in platitudes or euphemisms, they could be agreeing to something that is a completely different construct in their mind to what you think …’ (Interview 3)

While the participants recognised a need to be strong to support patients, an ability to feel emotion and empathise was considered to be a vital quality rather than a weakness: ‘There’s always someone who gets under your radar, and actually if there isn’t, you shouldn’t be here … If we’ve got to the point where this is tick-box [exercise] … you shouldn’t be here.’ (Interview 5)

The participants described how support from colleagues and an appreciation of the importance of PPD for patients enables them to cope with the difficult elements of end-of-life conversations: ‘If it’s patients that are ages with [the same age as] yourself … and you can draw a comparison with it, that can be quite upsetting. But equally it can be quite rewarding because you can then endeavour to meet their wishes.’ (Interview 2)

Theme 4: A journey from expectations to experience

The participants portrayed being unable to achieve a patient’s final requests as something that is emotional for themselves and the patient, and for which they will try to negotiate a solution. They also discussed the importance of ensuring that patients have realistic expectations of what is achievable to avoid disappointment. As staff initiate discussions in the majority of situations, a wish to minimise both staff and patient distress was identified as a barrier to discussing PPD. However, the participants recognised that they must ensure that reasons why PPD is not recorded are genuine rather than a ‘cop-out’:

All of the participants suggested that these discussions became easier over time. They described initial apprehension about end-of-life discussions, with a particular concern being patient distress. With experience participants have realised that although patients may be upset, they often value staff for being brave enough to explore these matters:

‘We need to really watch are we being paternalistic, why haven’t we discussed it … it [the form] says, “Might cause the patient distress” … how do we know unless we just touch on it a wee bit … they are giving you cues and

Further concerns were how to individualise conversations and use words such as ‘death’ and ‘dying’ without sounding final. With practice, the participants had developed techniques and confidence in having end-of-life conversations.

‘I was always a bit frightened … about upsetting the patient, but since I’ve been working here em I now realise that you’re no[t] really upsetting the patient, it’s just it’s a really sad topic.’ (Interview 6) © 2013 MA Healthcare Ltd

❛If managed well, end-of-life discussions can facilitate the development of trust and rapport between staff and patients.❜

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Such techniques included focusing on the positive aspects of early planning and use of carefully worded phrases to assess the patient’s response before initiating a more direct conversation: ‘Initially we were probably quite apprehensive about discussing things like that because a lot of our patients don’t actually acknowledge that they’re dying so it’s how to broach that with them … One of the ways that we probably start discussing it is not necessarily mentioning preferred place of death but, “When things get worse … where would you like to be cared for?” And that can kind of pre-empt a conversation then.’ (Interview 2)

An important way in which less-experienced participants had become more confident in discussing PPD was through learning from team members: ‘You can just nick [steal] those phrases because you know that they’re tried and tested … And that’s why you become more confident because you know that they work.’ (Interview 1) ‘I also found the discussions that would go to the senior medical team and clinical nurse specialists … really helpful as well … so it’s just about learning.’ (Interview 6)

The participants also discussed initial concern that recording PPD may result in a pressure to focus on planning. However, provided a discussion has been attempted, it is acceptable to record a reason why PPD is unknown at that time. Furthermore, while the formalisation of the PPD assessment process was initially daunting, staff realised that they had baseline skills in place already and that conversations were not as difficult as expected: ‘We do quite a lot of these things anyway and it’s just formalising them and putting them into a structure and a process … I think we would all agree that we felt a bit uncomfortable at first … but in hindsight … we realised that we had been doing it and it wasn’t so bad.’ (Interview 5)

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Discussion A key finding was that the participants appreciated the importance of discussing PPD. Appropriately timed discussions are recognised as having psychological benefits for patients as well as preventing adverse outcomes for patients and families. The advantages of assessing patient choices are well documented in the literature,

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including less inappropriate medical management, reduced risk of depression, improved caregiver adjustment to bereavement (Wright et al, 2008), and an opportunity to ‘work on issues of life closure’ (Quill, 2000). The staff involved in this study saw end-of-life discussions as an essential part of their role and felt it was their responsibility to initiate discussions early on. Participants in a study by Clayton et al (2005) that explored patient, carer, and palliative care staff beliefs about end-of-life discussions also felt it was important for the health professional to make end-of-life topics accessible. This is consistent with recommendations that health professionals should routinely raise end-of-life topics with patients (Larson and Tobin, 2000; Quill, 2000). However, some staff in the current study felt that other health professionals sometimes left end-of-life discussions to palliative care staff, suggesting there might be a need for more training in general medical settings. Balanced with the professional responsibility to address end-of-life preferences, the staff recognised the need to respect individual wishes. To avoid patient distress and preserve the staff– patient relationship, it was reported that the staff use open questions and interpret cues that enable them to assess patients’ understanding of their condition and ascertain how much they wish to discuss at that time. These findings are consistent with the results of Clayton et al (2005) and Munday et al (2009), who explored GPs’ and district nurses’ experiences of discussing PPD. The current research reflects the findings of Munday et al (2009), which highlighted factors that facilitate end-of-life conversations, such as staff–patient rapport. Preferences are typically viewed as being dynamic and as sometimes changing to the current location of care. This is evidenced in other research demonstrating that patients are more likely to choose to die at the hospice if they have had an inpatient admission (Arnold et al, 2013). Furthermore, staff in both studies discussed how PPD can become a negotiation between staff, carers, patients, and other teams when there is conflict between the patient’s wish and what is achievable. Staff in the current study acknowledged their central role in determining PPD, whereas GPs and district nurses often see other health professionals as having greater responsibility (Munday et al, 2009). In the present study the staff reflected on their own emotions, particularly how concern about causing patients distress could potentially lead them to evade these topics or use euphemistic vocabulary. It is known that health professionals

❛The opportunity to discuss choices at the end of life can have psychological benefits for patients, in a situation where they might have lost all sense of selfdetermination ...❜

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fear distressing their patients and may avoid difficult conversations in order to protect the patient or their self-regard (Loprinzi et al, 2000). However, a majority of people value clinicians who are willing to start end-of-life discussions in advance (Cox et al, 2006). Staff in the present study reported that while they were initially apprehensive about upsetting patients, they accepted that discussions are necessary and, with experience, they felt more comfortable in broaching them. Support and a chance to shadow more experienced team members are important for those new to end-of-life care, enabling them to improve their communication skills and choose the right time to initiate discussions. The staff recognised that it is essential to use clear language to gain accurate information on patient choice. This practice is supported by research illustrating that PPD and preferred place of care are separate concepts (Agar et al, 2008). The staff appeared less likely to rely on indirect sources of information such as behavioural cues and carer reports than in other studies (e.g. Munday et al, 2009). This may reflect differences in training, experience, opportunities to learn from others, or attitudes toward PPD.

Strengths and limitations This study provides unique and detailed insight into staff experiences of discussing PPD, focusing on themes that the participants raised as being important to them, rather than restricting the data into predefined categories. IPA explores experiences of small and relatively homogeneous samples, and one needs to be careful about generalising findings. This study included staff members in different roles, with varying levels of experience, all of whom were working at the same hospice. The sample was chosen to capture a variety of experiences; however, it was small owing to practical limitations such as staff availability and project duration. With a larger and more varied sample, similar research could offer even greater insight into the experience of discussing PPD.

Implications This research suggests that discussing PPD is important and beneficial for patients and staff. Participants in the current study described communication strategies and attitudes toward PPD that facilitate their ability to discuss PPD and cope with difficult aspects of these conversations. Although one participant questioned the optimal time to initiate PPD discussions, the consensus was that early conversations are beneficial and that in most cases the onus is on staff to make

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end-of-life topics accessible to patients. The introduction of the quality improvement process and formalisation of the system for recording PPD initially led staff to question the focus on planning, but staff now appreciate the value of regularly reviewing and recording PPD. These findings may inform training programmes for health professionals.

Future research Discussions of end-of-life matters differ depending on the context, staff experience, and staff–patient relationship. Thus, it would be interesting to include staff from different settings, such as hospitals and primary care. Furthermore, it may be of value to record PPD discussions to enhance our understanding of how they are accomplished and to provide a training resource. It would also be valuable to explore patients’ experiences of end-of-life discussions, which could arguably have greater impact on clinical practice.

Conclusion Determining and recording PPD is important for good quality palliative care service provision. Although discussing PPD can be complex and emotional, the staff felt that assessing patient wishes is important and beneficial for both patients and their families. Over time, the staff members had developed communication strategies that allow them to discuss PPD in an effective, sensitive, and patient-centred way. I● JPN Declaration of interests This study had no external sources of funding. The authors have no conflicts of interest to declare. Agar M, Currow DC, Shelby-James TM, Plummer J, Sanderson C, Abernethy AP (2008) Preference for place of care and place of death in palliative care: are these different questions? Palliat Med 22(7): 787–95 Arnold L, Finucane AM, Oxenham D (2013) Preferred place of death for patients referred to a specialist palliative care service. BMJ Support Palliat Care [epub ahead of print] doi:10.1136/bmjspcare-2012-000338 Barclay S, Maher J (2010) Having the difficult conversations about the end of life. BMJ 341: c4862 Brazil K, Bedard M, Willison K (2002) Factors associated with home death for individuals who receive home support services: a retrospective cohort study. BMC Palliat Care 1(1): 2 Broki JM, Wearden AJ (2006) A critical evaluation of the use of interpretative phenomenological analysis (IPA) in health psychology. Psychol Health 21(1): 87–108 Cantwell P, Turco S, Brenneis C, Hanson J, Neumann CM, Bruera E (2000) Predictors of home death in palliative care cancer patients. J Palliat Care 16(1): 23–8 Clayton JM, Butow PN, Tattersall MH (2005) When and how to initiate discussion about prognosis and end-of-life issues with terminally ill patients. J Pain Symptom Manage 30(2): 132–44 Cox A, Jenkins V, Catt S, Langridge C, Fallowfield L (2006) Information needs and experiences: an audit of UK

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❛Although discussing preferred place of death can be complex and emotional, the staff felt that assessing patient wishes is important and beneficial for both patients and their families.❜

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l Important ongoing projects–these may include a call for collaboration l Recently completed research, the intention being rapid spread of important results prior to a full write-up l Research, clinical innovation, or service development that may not be of sufficient size or implication to warrant a full-length paper, including novel research methodologies All appropriate submissions will be peer-reviewed as short reports and if accepted will be published both in print and online. Submissions should be no more than 1000 words in length including references and should include a brief explanation (not for publication) of why a short report is preferred to a full-length paper. Work previously communicated as a conference abstract would be welcome but must be written up in an original short report format. Short reports should be submitted via the usual channel: www.ijpn.co.uk/contribute.shtml The Editor will be happy to respond to any queries: [email protected]

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Discussing preferred place of death with patients: staff experiences in a UK specialist palliative care setting.

National end-of-life care policies propose that health professionals regularly discuss matters such as preferred place of death (PPD) with patients...
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