title: A discourse analysis of difficult clinical situations in relation to nutrition and hydration during end of life care.
abstract: OBJECTIVE
  The following discussion builds upon a previous publication that reported on the perceptions and discourses of palliative care nurses and doctors in relation to nutrition and hydration at the end of life. The aim of this paper is to report the discourses of nurses and doctors in relation to the challenges they faced when managing the care of patients with severe brain injury vs. the clearer cut situations when caring for terminally ill patients with cancer. The objectives of the study were to: explore the tensions in the discourses during end of life care, explore the challenges regarding nutrition and hydration at the end of life.
  
  
  BACKGROUND
  The decision to withdraw life support seems to be made more readily than the decision to withdraw nutrition and hydration at the end of life. The abatement of nutrition and hydration during the terminal phase of life is a controversial issue for a range reasons. Indeed, whilst it is accepted practice in the palliative care setting, nurses and doctors often struggle with the idea.
  
  
  METHODS
  The design for this study used discourse analysis framed by a post structural framework.
  
  
  METHODS
  Focus groups were conducted with nurses working in palliative care units. Single interviews were conducted with doctors from a tertiary palliative care unit.
  
  
  RESULTS
  The findings revealed contesting discourses involving quality of life and the prolongation of life.
  
  
  CONCLUSIONS
  The provision of food and fluid has profound emotional and social meanings for patients and families. The study reported here examined these issues with health professionals. The findings point to the challenges and tensions faced by health professionals in relation to decision making and medical hydration during end of life care. The concern is that tensions arise when decisions need to be made and how best to make these. The contesting discourses for nurses and doctors when nutrition and hydration is ceased involve maintaining quality of life vs. the prolongation of life.
  
  
  CONCLUSIONS
  Medical and nursing staff have different attitudes and beliefs towards end of life care. Tensions arise when decisions need to be made based on quality of life or prolongation of life. The successful merging of curative and palliative care is not without challenges. There has been little exploration of this situation.
authors.affiliation: School of Nursing and Midwifery, University of Newcastle, Callaghan Campus, Callaghan NSW, Australia. Pamela.vanderiet@newcastle.edu.au
authors.forename: Pamela
authors.initials: P
authors.lastname: van der Riet
authors.forename: Isabel
authors.initials: I
authors.lastname: Higgins
authors.forename: Phillip
authors.initials: P
authors.lastname: Good
authors.forename: Ludmilla
authors.initials: L
authors.lastname: Sneesby
mesh_terms: D005440:Fluid Therapy; D017144:Focus Groups; D006801:Humans; D009752:Nutritional Status; D013727:Terminal Care