title: The study protocol of: 'Initiating end of life care in stroke: clinical decision-making around prognosis'.
abstract: BACKGROUND
  The initiation of end of life care in an acute stroke context should be focused on those patients and families with greatest need. This requires clinicians to synthesise information on prognosis, patterns (trajectories) of dying and patient and family preferences. Within acute stroke, prognostic models are available to identify risks of dying, but variability in dying trajectories makes it difficult for clinicians to know when to commence palliative interventions. This study aims to investigate clinicians' use of different types of evidence in decisions to initiate end of life care within trajectories typical of the acute stroke population.
  
  
  METHODS
  This two-phase, mixed methods study comprises investigation of dying trajectories in acute stroke (Phase 1), and the use of clinical scenarios to investigate clinical decision-making in the initiation of palliative care (Phase 2). It will be conducted in four acute stroke services in North Wales and North West England. Patient and public involvement is integral to this research, with service users involved at each stage.
  
  
  CONCLUSIONS
  This study will be the first to examine whether patterns of dying reported in other diagnostic groups are transferable to acute stroke care. The strengths and limitations of the study will be considered. This research will produce comprehensive understanding of the nature of clinical decision-making around end of life care in an acute stroke context, which in turn will inform the development of interventions to further build staff knowledge, skills and confidence in this challenging aspect of acute stroke care.
authors: School of Healthcare Sciences, Bangor University, Bangor, Gwynedd LL57 2EF UK.
authors: Christopher R
authors: CR
authors: Burton
authors: International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG UK.
authors: Sheila
authors: S
authors: Payne
authors: International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4YG UK.
authors: Mary
authors: M
authors: Turner
authors: School of Nursing and Midwifery, Deakin University, 221 Burwood Hwy, Burwood, Melbourne, VIC 3125 Australia.
authors: Tracey
authors: T
authors: Bucknall
authors: School of Healthcare Sciences, Bangor University, Bangor, Gwynedd LL57 2EF UK.
authors: Jo
authors: J
authors: Rycroft-Malone
authors: University of Manchester, MAHSC, Salford Royal Foundation Trust, M6 8HD Salford, UK.
authors: Pippa
authors: P
authors: Tyrrell
authors: University of Bradford, Richmond Road, Bradford, Yorkshire, BD7 1DP UK.
authors: Maria
authors: M
authors: Horne
authors: School of Healthcare Sciences, Bangor University, Bangor, Gwynedd LL57 2EF UK.
authors: Lupetu Ives
authors: LI
authors: Ntambwe
authors: University of Manchester, Oxford Road, Manchester, M13 9PL UK.
authors: Sarah
authors: S
authors: Tyson
authors: Betsi Cadwaladr University Health Board, Ysbyty Eryri, Caernarfon, LL55 2YE UK.
authors: Helen
authors: H
authors: Mitchell
authors: School of Healthcare Sciences, Bangor University, Bangor, Gwynedd LL57 2EF UK.
authors: Sion
authors: S
authors: Williams
authors: Betsi Cadwaladr University Health Board, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd, LL57 2PW UK.
authors: Salah
authors: S
authors: Elghenzai
mesh_terms: D001293:Attitude to Death; D000066491:Clinical Decision-Making; D002985:Clinical Protocols; D003142:Communication; D004739:England / Q000453:epidemiology; D005260:Female; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D010166:Palliative Care; D011379:Prognosis; D036301:Qualitative Research; D020521:Stroke / Q000401:mortality / Q000628:therapy*; D013727:Terminal Care; D014852:Wales / Q000453:epidemiology
keywords: Acute stroke; Decision making; Dying trajectories; End of life care; Implementation; Palliative care