End of life decisions and practices : the experiences of doctors in Australia

Abstract

This research investigates how physicians understand, practice and experience end-of-life care in the context of Australian palliative and critical and acute settings. Particular attention is given to how they negotiate decisions and practices that are also situation specific and multitudinally influenced. By adopting a critical realist framework that draws on complexity theory, an interpretive account is provided through thematic analysis to give an understanding of the ambiguity and inconsistency of end-of-life care practices and experiences reported in the available literature. New knowledge is bolstered by focusing specifically on Australian end-of-life settings and by also considering the physicians' positive experiences and the coping strategies they utilise to counter aversive experiences. A total of thirteen physicians that included seven palliative specialists, three intensive care specialists, a respiratory-thoracic specialist, and two GPs identified how negotiating multiple macro, meso and micro influences affected the way they understood, practiced and experienced end-of-life care. Religious, political and professional doctrines, and personal beliefs and attitudes played out at the bedside in non-predictive and inconsistent ways. Physicians were not necessarily constrained by legal and professional imperatives, especially when death was regarded as hastened, but were guided by an internalised moral and ethical structure developed from multiple influences across the lifespan. The physicians' capacity for agency within individual contexts and the efficacy with which they negotiated practices shaped their subsequent experiences. In addition to fostering a professional and empathic relationship with dying patients and patient loved ones, multifaceted requirements for end-of-life care saw physicians adopt multiple roles, some of which included research, patient advocacy, and navigating institutional and administrative barriers. Although the physician's emotional self-efficacy and the positive experiences they drew from end-of-life care strongly mediated many of the aversive experiences they encountered, it was not always so. Implicating governance, resourcing, and training and support, physicians also experienced many negative aspects of care which exposed opportunities for research that targets interventions at macro, meso and micro levels.

Date of Award	2013
Original language	English