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Doctors’ understanding of palliative care Barbara Hanratty Division of Public Health, University of Liverpool, Liverpool, Derek Hibbert Division
of Primary Care, University of Liverpool, Liverpool, Frances Mair Department of General Practice and Primary
Care, University of Glasgow, Glasgow, Carl May Centre for Health Services Research, University of Newcastle
upon Tyne, Newcastle upon Tyne, Chris Ward Cardiologist, Dundee (formerly of Wythenshawe Hospital,
Manchester), Ged Corcoran University Hospital Aintree, Liverpool, Simon Capewell Division of Public Health,
University of Liverpool, Liverpool and Andrea Litva Division of Primary Care, University of Liverpool, Liverpool
Palliative care has been challenged to share its message with a wider audience, and for
many years it has been articulating an approach that is suitable for all patients. However, it
is not clear how widely this message has been accepted. As part of a study into end-of-life
care for heart failure, we conducted seven focus groups with doctors in general practice,
palliative medicine, cardiology, geriatrics and general medicine. In these, we explored
doctors’ understanding of palliative care. Participants displayed a reasonable grasp of
the wider concept of palliative care, but the specialists’ role was ill-defined, reflected
in scepticism about their place outside of cancer. Perceptions of palliative care fell into
three broad areas: it was more than a service, about managing dying, and the concern of
nurses, rather than doctors. Palliative care was welcomed as providing permission to fail,
whilst representing a dilemma between quantity and quality of life for the interviewees. Our
work suggests that specialist palliative care has been partially successful in getting their
message across, and poor understanding or receptivity are not major barriers to
implementing palliative care. Educational or other interventions to implement change in
palliative care need to acknowledge the complex interaction of factors influencing
physicians’ behaviour. Palliative Medicine 2006; 20: 493�497
Key words: knowledge attitudes practice; palliative care; qualitative research
Introduction
Palliative care has been challenged to share its message
with a wider audience,1 and through education and
example, its proponents have been working to improve
care for the majority for nearly 40 years. However,
despite the rapid growth of specialist palliative services
and ideas, it is still widely held that care of the dying is
poor, particularly in hospitals.2�4 The approach espoused
by the hospice movement is potentially relevant to every
area of medicine,5 and the key to improving health
care of the dying must lie in mainstream services.
Specialist palliative care services see only a small
minority of dying patients, most of whom have cancer.6
In other diagnostic groups, such as respiratory and
cardiac disease, patients’ needs for care and support
often go unmet.7,8 As the debate over widening the
responsibilities of the specialist services continues, it is
timely to stop and consider what doctors, in general,
understand by palliative care.
Previous investigations into doctors’ perceptions of
palliative care have often focussed on exploring choice of
topics for educational interventions or testing knowl-
edge.9,10 We know much less about how palliative care is
interpreted or conceptualized.11 This is important, as
acquiring knowledge is only one step towards changing
practice. The influence of different factors on the
complex path between education and behavioural change
is increasingly recognized as important.12,13 Awareness of
doctors’ beliefs, for example, is thought to be crucial.14
The hospital is a particularly important setting. Al-
most half of the UK population die in hospital,15 and
popular belief holds that hospital practitioners may be
more reluctant than their community colleagues to adopt
holistic approaches to care.
We conducted a series of seven focus groups with
doctors, exploring views on the care of people dying with
heart failure. Heart failure is typical of chronic progres-
sive diseases in that a range of specialities may be
involved in patient management. Thus, our participants
from general practice, palliative medicine, geriatrics,
cardiology and general medicine form a cross-section of
hospital and community doctors involved in chronic care.
In this paper, we aim to provide essential baseline
information for the future development of services and
a palliative care approach, by reporting on doctors’
Address for correspondence: Barbara Hanratty, MRC Special Training Fellow, Division of Public Health, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK. E-mail: b.hanratty@liverpool.ac.uk
Palliative Medicine 2006; 20: 493�497
# 2006 Edward Arnold (Publishers) Ltd 10.1191/0269216306pm1162oa
understanding of palliative care, as expressed during the
focus group discussions.
Methods
We conducted seven focus groups with doctors expected
to have a role in the care of patients with heart failure.
The participants were drawn from one NHS region in England, and recruited via professional bodies or direct
approaches. The groups ranged in size from four to six
doctors (five general practitioners (GPs), five academic
GPs, five district general cardiologists, five tertiary centre
cardiologists, six geriatricians, six palliative care physi-
cians, four general physicians). Each group consisted of
doctors working at consultant level in the same speciality
to maximize openness and facilitate relaxed discussion. Apart from the general physicians, half of whom were
women, there was only one female doctor in each of the
group of GPs, cardiologists and geriatricians, and one
male doctor in the palliative care group. Data to address
doctors’ understanding of palliative care were derived
from the opening question (Can you tell me what you
understand by palliative care?) and all other direct or
implied references to palliative care during the discus- sion. The main focus of the discussion was on the
doctors’ perceptions of the need for palliative care for
patients with heart failure, and what form that does and
should take. The discussion thus encompassed both the
theoretical and practical aspects of palliative care, and
allowed the participants to elaborate their understanding
of palliative care throughout.
Two researchers were present at all the groups, one to facilitate and one to observe. The meetings were recorded
and transcribed and QSR Nvivo software was used for
data management.16 Data analysis used the principles of
constant comparison,17 with two researchers coding and
categorizing all the transcripts. Themes were identified
independently, and discrepancies discussed. Preliminary
results were reviewed and discussed by the multi-
disciplinary group of authors. The focus of this analysis was on the doctors who were not specialists in palliative
care, and data from the specialists’ discussion were used
to compare and contrast with the non-specialist view-
point.
Results
Discussion was lively in all the groups except the meeting
of general physicians. We cannot be certain of the reasons
for this. This group was the most difficult to arrange,
which raises questions as to the salience of the topic for
these doctors. Hierarchical relations within the group
may also have dampened the discussion, and holding the
meeting at lunchtime meant that the pressures of work
were not far away. The specific findings are presented in
terms of the main themes arising from the discussion. This is not meant to imply that all the doctors shared one
view. Development and refining of ideas was apparent
throughout the interviews.
Much more than a service
It was clear from the way that participants referred to
palliative care that it was conceived as much more than a service. Terms, such as ‘mode’, ‘concept’ and ‘situation’,
were used when discussing palliative care. Some framed
their talk in aspirational terms, referring to their ideal as
‘proper palliative care’, or ‘a thorough palliative care
approach’. The appropriateness of palliative care was
not questioned, and even when the group did not
share definitions, they were united in their support of
palliative care as an ideal. There was also a strong sense of the holistic aspects of palliative care throughout the
groups.
I think in a perfect world you see it as a holistic ideal,
encompassing the patient, their family and the pro-
blems the patient has, the problems the family has erm
and both of their expectations of the process that
they’re going through. That would be an ideal world. (GP 1/3)
The importance of looking at the whole picture including
psychosocial issues was expressed in most groups. GPs
and cardiologists also discussed the spiritual aspects of
care, though there was no particular indication that they
felt it was relevant to their work. Communication with
patients and carers was also acknowledged as a major aspect of palliative care.
I think. . . it’s a kind of cultural recognition of whats
death. And, like you were talking about, there didn’t
used to be palliative specialists, I think there were
often priests that would help. (GP 2/1)
Erm I think palliative care depends on patients and
their carers, certainly in cancer but also in heart
failure, understanding the condition, the terminal
nature of their condition, and what we’re trying to
do for them. (Cardiologist 4)
Palliative care was also portrayed as a phase in time,
when the goals of medical management change and death is recognized. It was only through discussion in the
groups that the difficulties of recognizing the right time
to switch to palliative care surfaced as a major challenge.
A change of gear, a diagnosis of dying, switching from
erm officiously striving to keep someone alive er, to
where the main emphasis should be on comfort.
(Geriatrician 3)
494 B Hanratty et al.
Managing dying
The management of dying was an underlying theme in
much of the discussion. Participants drew a picture of
themselves as conductors of the services around their
patients, co-ordinating and facilitating. For some, this
encompassed the environment and the social context, as
well as the medical care. The geriatricians’ discussion
suggested that they felt that they should strive to manage the death, whilst the cardiologists were honest in acknow-
ledging that they made this switch late in the illness.
I think what you’re trying to do with palliative care is
provide the sort of psychological, social support to
relatives and patients and to hopefully have a co-
ordinated approach so it doesn’t collapse at the
weekends, things like that. (GP 1/1)
It’s a co-existent approach, so you keep optimizing,
keep revising the treatment and balancing the combi-
nation. But then you are also aware of the other
factors that are coming in and you also then get a
picture in your mind that is a road to deterioration.
And yes we might stop hammering the ACE inhibitors because they’re clearly not effective and we may be
bringing them something else for the symptoms, but
you’re still maintaining that approach. (Geriatrician 4)
It was only amongst the general physicians that some-
thing closer to the concept of ‘palliative care from
diagnosis’ was discussed. Guidance and pathways for
managing the final 48 hours of life were considered valuable, but only a part of palliative care.
Not very medical
The role of the nurse was emphasized strongly by most
groups, and there was a parallel perception that palliative
care was not necessarily the province of the doctor. It was
‘not very medical’, and ‘largely nursing based care for
people who are terminal’. There seemed to be a complex
set of conflicting motives here. Firstly, it was apparent that palliative care was perceived as being time consum-
ing, and time was openly prized by many of the doctors.
Secondly, palliative care was seen as straightforward
medical practice, and in the words of one of the
consultants in palliative medicine, was ‘not glamorous’.
If the status of doctors is enhanced by displays of
expertize and technical knowledge, palliative care offers
a burden with no return. Labelling palliative care as the role of the nurse perhaps legitimizes the doctor’s choice
not to become involved. However, the concept of
palliative care as an ideal was pervasive in the groups,
and some participants were clearly ambivalent about the
role they played. The presentation of the nurse as having
the skills and the time to provide better care for the dying
may well have been a direct and pragmatic response to
the time constraints of their own jobs.
Quantity versus quality
Many of the treatments for heart failure address both
symptoms and survival, so the switch from rescue to comfort may not be clear-cut. Some of our participants
appeared to confuse the introduction of palliative care
with a direct path to death and focus entirely on quality
of life. Palliative care was described by one geriatrician as
‘quite negatively focussed in terms of survival’. The idea
that different approaches may co-exist, with shades of
grey in patient management, had not been universally
adopted.
The role of the specialist
Neither the GPs nor the hospital doctors expressed clear ideas of how palliative medicine should contribute to
heart failure care. A number had unsuccessfully tried to
refer patients to their local specialist service, and were
disparaging about the narrow remit of the specialist
palliative care service. However, the strongest emotion
was expressed by some of the GPs and geriatricians, who
were keen not to hand over their patients to another
specialty.
After all you know the mortality of life is 100%,
everybody is dying, so what is the difference between
palliative care and good medical practice? You know
there are textbooks of palliative care and there are
palliative care ‘specialists’, why palliative care, why not
just an ordinary doctor? Its sort of a speciality driven by prognosis rather than anything else, because there
are lots of chronic disease that we look after that we
can’t cure they don’t come under the umbrella of
palliative care � diabetes for example. (GP 1/3)
A few individuals described examples of successfully
using advice from their local consultants, but others felt
that palliative care physicians may not have the expertize that they had to deal with heart failure. The palliative
care doctors’ vision of themselves as educating health
professionals to provide most of the support had, on the
whole, not been embraced by the other doctors. The
general physicians acknowledged that there was ‘a lot of
specialism in palliative care already that we don’t really
use sufficiently. . .’ (General Physician 1/4), and their
communication skills were highlighted in particular.
Permission to fail
The cardiologists were frank in admitting their dislike of failure, which was how they perceived the death of a
patient. In other groups, failure was not always articu-
lated, but it was apparent as they described struggling to
find the right words for relatives, the limited time they
had for dying patients on ward rounds and the difficulty
of accurate prognostication. The palliative care physi-
cians were widely admired for having the ability to ‘fail
well’. The introduction of the specialty appeared to be a
Doctors’ understanding of palliative care 495
relief for some doctors, and permission to let go.
However, a number of doctors in different specialities
were concerned at the message this sent to the patients, and one described the attention from specialists as
‘ghoulish’.
The specialists’ view
Discussion amongst the consultants in palliative medi-
cine displayed a shared clarity over their own role in
patient care, as advisors, educators, and expert resources,
there to take a holistic view. Their experience of confu-
sion, ignorance and misperceptions about their role from non-specialist doctors supported much of what had been
said in the other groups. The concept of looking at
palliative care patients ‘with the right eyes’ was how one
participant eloquently described the way in which they
wished to promote a different perspective on patient care.
Respect for the skills of the other specialties pervaded the
discussion, and a willingness to take some responsibility
for any uncertainty that surrounds their role.
But unless you have the right eyes to actually identify
what can be done within that generalist setting. . . there
is a lot of ignorance around about what can be done.
(Palliative Care Physician 3)
I think primary care can be very uncertain about when
to refer to specialist palliative care. . . a lot of it is our
fault, because we could all reel off the WHO definition
and the Calman Hine definition. . . but we’re not very
good at marketing and making it clear as to when we
get involved. (Palliative Care Physician 1)
That doesn’t mean we’ve got all the knowledge and
they need all the teaching. . . its working as a team and
learning how best to get things done. (Palliative Care
Physician 6)
Discussion
Our study participants displayed an understanding of the
wider concept of palliative care, but relatively poor grasp
of the role of the specialist in palliative medicine, and
scepticism about their role beyond cancer. There was also
a strong perception that palliative care is the province of
nurses rather than doctors. The other area of uniformity
across the groups was a feeling that palliative care was something important, even though some of the non-
specialists had had difficulty in coming to an under-
standing of how all the health professionals fitted in, and
had some uncertainty about what it meant in practice.
Differences between the specialties were more clear-cut.
The GPs and geriatricians were generally familiar with
talking about death, appeared to be the most receptive to
the concepts of palliative care. The cardiologists and
physicians were less comfortable with the death of
patients, perhaps because it ill fits their perception of
their role and the day-to-day orientation of their practice. They welcomed the practical help of the specialists.
Limitations
The themes described here offer a unique insight into
doctors’ understanding of palliative care, and raise issues
for further research. However, we acknowledge that our participants’ views may not be typical. With the excep-
tion of the GPs who received locum payments, they were
not rewarded for their involvement. The extent to which
the views offered provide an accurate picture of physi-
cians’ practice is unknown, and the use of standard
definitions by some participants to describe palliative
care may reflect a willingness to conform to accepted
norms. By combining responses to a direct question with implied and direct references throughout the discussions,
we have tried to overcome this potential limitation. At
times, the term ‘palliative care’ was used by interviewees
to refer to specialist services and, elsewhere, to a
palliative care approach. Which of these meanings was
being used was usually clear from the context of the
discussion. In general, we chose not to interrupt the flow
of discussion by stopping repeatedly for clarification. The focus groups consisted of single speciality groups;
either all GPs, or all doctors from one hospital speciality.
The advantages of this approach were that the partici-
pants had a shared understanding of each other’s work.
In many cases, they already knew each other, which
helped to overcome some of the barriers to free-flowing
conversation often found in the initial stages of focus
groups. Single speciality groups also helped minimize the potential for disruptive power relations between the
interviewees. Had the groups been mixed between GPs
and consultants, it is possible that perceptions of a higher
status amongst hospital doctors may have prevented their
GP colleagues from expressing themselves honestly.
Potential disadvantages of not mixing the specialities
included the possibility that the interviewees would have
a uniform view on some issues, and there would be few challenging voices. Conforming to group norms could be
especially evident amongst what is an inherently con-
servative group.
Implications
Our participants were familiar with the concepts of palliative care. Their thoughtful discussion of the holistic
aspects of care of the dying suggests that a lack of
knowledge would not prevent them from delivering good
palliative care. Most participants also knew their local
consultants in palliative medicine, yet many admitted to
little idea of what they actually did. This may be because
working practices are different in palliative care; the
multi-disciplinary team and the advisory nature of much
496 B Hanratty et al.
of the doctors’ work are better developed than in many
other specialities. However, the strong perception that
end-of-life care is a nursing role may mean that doctors fail to see the relevance to their own work. The specialist
palliative care team may inadvertently reinforce such
perceptions, by the way in which they work. Qualities
that contribute to an effective team � valuing the
contribution of different disciplines, respect for alterna-
tive viewpoints, for example � can also be interpreted as
signs that a doctor is not needed. Hierarchies are still
entrenched in medical practice, and this must underpin many of these challenges.
The hospice movement has been a successful advocate
for the development of holistic care of the dying.
Palliative care has a place in many undergraduate and
postgraduate curricula, albeit limited.18,19 The deficien-
cies of the knowledge base have been well described in
recent years,18�22 and educators are increasingly looking
beyond the sharing of knowledge, to focus on more effective ways of changing behaviour.23,24 Our partici-
pants are likely to be typical of today’s consultants and
GPs, having had little or no formal training in palliative
care. Whilst not lacking knowledge, they displayed
attitudes that may prevent them from providing good
palliative care. For example, the ‘failure’ of death was
discussed, as was the negative focus on survival within
palliative care. For many doctors, the attitudes, beliefs, and self-perceptions that underpin professional practice
may be potent barriers to holistic care.12 Our work
certainly suggests that greater emphasis on these within
educational strategies may be beneficial. Challenging
attitudes to medical roles is a long term project, but
change is more likely as palliative care becomes firmly
established within medical schools. Evaluative research
into the most effective approaches to professional behavioural change within palliative care settings would
be helpful.
Acknowledgements
This study would not have been possible without the
participants giving generously of their time and energy to participate in the focus groups. We gratefully acknowl-
edge financial support from the Mersey Primary Care
Research and Development Consortium and the Scien-
tific Foundation Board of the Royal College of General
Practitioners.
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