title: Is a good death possible in Australian critical and acute settings?: physician experiences with end-of-life care.
abstract: BACKGROUND
  In Australia approximately 70% of all deaths are institutionalised but over 15% of deaths occur in intensive care settings where the ability to provide a "good death" is particularly inhibited. Yet, there is a growing trend for death and dying to be managed in the ICU and physicians are increasingly challenged to meet the new expectations of their specialty. This study examined the unexplored interface between specialised Australian palliative and intensive care and the factors influencing a physician's ability to manage deaths well.
  
  
  METHODS
  A qualitative investigation was focused on palliative and critical/acute settings. A thematic analysis was conducted on semi-structured in-depth interviews with 13 specialist physicians. Attention was given to eliciting meanings and experiences in Australian end-of-life care.
  
  
  RESULTS
  Physicians negotiated multiple influences when managing dying patients and their families in the ICU. The way they understood and experienced end-of-life care practices was affected by cultural, institutional and professional considerations, and personal values and beliefs. Interpersonal and intrapsychic aspects highlighted the emotional and psychological relationship physicians have with patients and others. Many physicians were also unaware of what their cross-disciplinary colleagues could or could not do; poor professional recognition and collaboration, and ineffective care goal transition impaired their ability to assist good deaths. Experience was subject to the efficacy of physicians in negotiating complex bedside dynamics.
  
  
  CONCLUSIONS
  Regardless of specialty, all physicians identified the problematic nature of providing expert palliation in critical and acute settings. Strategies for integrating specialised palliative and intensive care were offered with corresponding directions for future research and clinical development.
authors.affiliation: Centre for Health Research, School of Medicine, University of Western Sydney, Campbelltown, Australia.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Trankle
keywords: Australia; End-of-life care; Good deaths; Intensive care; Palliative care; Qualitative research