Clinical thinking, knowledge and the referral practices of consultant physicians to specialist palliative care services : an interpretative phenomenological analysis

摘要

Aim and research questions: The aim of the study described in this thesis was to explore the personal and professional experience of consultant cardiologists, oncologists and old age psychiatrists and the consequent impact on referral practices to specialist palliative care services. The research questions attempted to develop an understanding of the relationship between their perceptions of and attitudes to palliative care and consequent decision making. Methods: The chosen methodological approach was interpretative phenomenological analysis (IPA) which supported exploration of the consultants experience together with facilitating their understanding of their idiographic experience. Ten minimally structured individual interviews were conducted with four cardiologists, four oncologists and four old age psychiatrists. Consistent with the philosophical approach of IPA their individual experiences were analysed - descriptively, conceptually and linguistically. The experiences of each consultant group were then combined to elicit their shared experience before being compared across group. The work was interpreted by detailed discussion which considered the structural context, the influence of the macro, meso and micro levels of health care and the political, historical and clinical aspects of palliative care on their experience. Deepr exploration was undertaken by considering the phenomenological concept of the life-world, 'habitus' and the philosophical and theoretical contexts of knowing and clinical thinking. The use of language and specifically metaphor supported increased understanding. Findings: The consultants' experiences (both personal and professional) reflected the primacy of their clinical expertise and their uncertainty as to whether a palliative care referral was always in the best interests of the patient group. The requirement for prognostication, identifying the transitions from active to palliative care was especially problematic for heart failure and dementia patients due to the uncertain disease trajectory. Many of the consultants identified the personal cost and clinical dilemmas of determining the end of life. Their stories, in particular identified the difficulties in establishing and communicating an end of life prognosis reflecting their unique personal and professional responsibility as medical consultants which contradicts the perceived contemporary dominance of multi professional working.