title: "It's Somebody else's responsibility" - perceptions of general practitioners, heart failure nurses, care home staff, and residents towards heart failure diagnosis and management for older people in long-term care: a qualitative interview study.
abstract: BACKGROUND
  Older people in care-facilities may be less likely to access gold standard diagnosis and treatment for heart failure (HF) than non residents; little is understood about the factors that influence this variability. This study aimed to examine the experiences and expectations of clinicians, care-facility staff and residents in interpreting suspected symptoms of HF and deciding whether and how to intervene.
  
  
  METHODS
  This was a nested qualitative study using in-depth interviews with older residents with a diagnosis of heart failure (n=17), care-facility staff (n=8), HF nurses (n=3) and general practitioners (n=5).
  
  
  RESULTS
  Participants identified a lack of clear lines of responsibility in providing HF care in care-facilities. Many clinical staff expressed negative assumptions about the acceptability and utility of interventions, and inappropriately moderated residents' access to HF diagnosis and treatment. Care-facility staff and residents welcomed intervention but experienced a lack of opportunity for dialogue about the balance of risks and benefits. Most residents wanted to be involved in healthcare decisions but physical, social and organisational barriers precluded this. An onsite HF service offered a potential solution and proved to be acceptable to residents and care-facility staff.
  
  
  CONCLUSIONS
  HF diagnosis and management is of variable quality in long-term care. Conflicting expectations and a lack of co-ordinated responsibility for care, contribute to a culture of benign neglect that excludes the wishes and needs of residents. A greater focus on rights, responsibilities and co-ordination may improve healthcare quality for older people in care.
  
  
  BACKGROUND
  ISRCTN19781227.
authors.affiliation: Durham Clinical Trials Unit, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Wolfson Research Institute, University Boulevard, Stockton-on-Tees TS17 6BH, UK. h.j.close@durham.ac.uk
authors.forename: Helen
authors.initials: H
authors.lastname: Close
authors.forename: Helen
authors.initials: H
authors.lastname: Hancock
authors.forename: James M
authors.initials: JM
authors.lastname: Mason
authors.forename: Jerry J
authors.initials: JJ
authors.lastname: Murphy
authors.forename: Ahmet
authors.initials: A
authors.lastname: Fuat
authors.forename: Mark
authors.initials: M
authors.lastname: de Belder
authors.forename: A Pali S
authors.initials: AP
authors.lastname: Hungin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D019468:Disease Management; D005260:Female; D058005:General Practitioners / Q000523:psychology*; D006333:Heart Failure / Q000175:diagnosis* / Q000523:psychology / Q000628:therapy*; D006801:Humans; D008134:Long-Term Care / Q000379:methods / Q000523:psychology; D008297:Male; D009726:Nurses / Q000523:psychology*; D010358:Patient Participation / Q000379:methods / Q000523:psychology*; D010465:Perception; D012941:Social Responsibility; D011795:Surveys and Questionnaires