title: Clinical decision making in the recognition of dying: a qualitative interview study.
abstract: BACKGROUND
  Recognising dying is an essential clinical skill for general and palliative care professionals alike. Despite the high importance, both identification and good clinical care of the dying patient remains extremely difficult and often controversial in clinical practice. This study aimed to answer the question: "What factors influence medical and nursing staff when recognising dying in end-stage cancer and heart failure patients?"
  
  
  METHODS
  This study used a descriptive approach to decision-making theory. Participants were purposively sampled for profession (doctor or nurse), specialty (cardiology or oncology) and grade (senior vs junior). Recruitment continued until data saturation was reached. Semi-structured interviews were conducted with NHS medical and nursing staff in an NHS Trust which contained cancer and cardiology tertiary referral centres. An interview schedule was designed, based on decision-making literature. Interviews were audio-recorded and transcribed and analysed using thematic framework. Data were managed with Atlas.ti.
  
  
  RESULTS
  Saturation was achieved with 19 participants (7 seniors; 8 intermediate level staff; 4 juniors). There were 11 oncologists (6 doctors, 5 nurses) and 8 cardiologists (3 doctors, 5 nurses). Six themes were generated: information used; decision processes; modifying factors; implementation; reflecting on decisions and related decisions. The decision process described was time-dependent, ongoing and iterative, and relies heavily on intuition.
  
  
  CONCLUSIONS
  This study supports the need to recognise the strengths and weaknesses of expertise and intuition as part of the decision process, and of placing the recognition of dying in a time-dependent context. Clinicians should also be prepared to accept and convey the uncertainty surrounding these decisions, both in practice and in communication with patients and carers.
authors.affiliation: St Benedict's Hospice, St Benedict's Way, Sunderland, SR2 0NY, UK. drpaulmtaylor@gmail.com.
authors.forename: Paul
authors.initials: P
authors.lastname: Taylor
authors.affiliation: Columbia University School of Nursing and the Visiting Nurse Service of New York, 617 W 168th Street, New York, NY, 10032, USA.
authors.forename: Dawn
authors.initials: D
authors.lastname: Dowding
authors.affiliation: Hull York Medical School, University of Hull, Hertford Building, Hull, HU6 7RX, UK.
authors.forename: Miriam
authors.initials: M
authors.lastname: Johnson
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D000066491:Clinical Decision-Making / Q000379:methods*; D004739:England; D006333:Heart Failure / Q000628:therapy; D006801:Humans; D008505:Medical Staff, Hospital / Q000592:standards*; D009369:Neoplasms / Q000628:therapy; D009741:Nursing Staff, Hospital / Q000592:standards; D036301:Qualitative Research; D013222:State Medicine; D013727:Terminal Care / Q000592:standards*; D019452:Terminally Ill; D062606:Tertiary Care Centers / Q000592:standards
keywords: Clinical decision making; Diagnosis; Dying