Not intervening as a form of care: Negotiating medical practices at the end-of-life.

Biomedicine is organized around interventions. Despite growing concern about overtreatment in healthcare systems, not intervening can still raise questions about potential negligence and the quality of care. Based on ethnographic fieldwork with palliative care teams in England, we explore the work palliative care specialists do to reduce and sometimes halt interventions for patients at the end-of-life, in a general medical environment that is largely interventionist. We describe how judgments about what is an action or not aren't based on obvious or agreed criteria, but ultimately according to what different actors feel constitutes the best form of care. In other words, the underlying values that shape ideas of care determine how action and inaction are nominated, and not the other way around.

How much information is 'reasonable'? A qualitative interview study of the prescribing practices of palliative care professionals.

BACKGROUND: Prescribing clinicians have to negotiate ambiguities around information provision and consent for medications on a daily basis, despite the availability of professional guidance. AIM: This study aims to explore some of the many factors prescribing clinicians in the United Kingdom take into account when deciding what information to give to patients about medication choices, and when. DESIGN: In depth face-to-face interviews, utilising both a hypothetical scenario and semi-structured prompts, were conducted in order to elicit extended reflections on how clinicians individually work through such dilemmas and make decisions. SETTING/PARTICIPANTS: Ten prescribing clinicians (doctors and nurses) from a large combined team of National Health Service (NHS) secondary and community palliative care providers in England. RESULTS: Palliative care staff regularly face choices about information provision in prescribing discussions, in particular when considering whether information might increase distress. Participants presented three overlapping framings that helped them assess the range of factors that could potentially be taken into account; (1) assessing the individual patient, (2) tailoring the provision of information and (3) jointly forming a plan. CONCLUSIONS: Information provision about medication choices and effects is a demanding, ongoing process, requiring nuanced judgements that constitute an unacknowledged yet significant aspect of clinical workload. Although current medical guidelines allow clinical discretion about information provision, this can leave individual clinicians feeling vulnerable. Further evolution of guidelines needs to establish a more sophisticated way to acknowledge professional and legal requirements, whilst also promoting professional autonomy and judgement.

Making a decision about surgery for female urinary incontinence: a qualitative study of women's views.

INTRODUCTION AND HYPOTHESIS: This qualitative interview study explores aspects women with urinary incontinence(UI) reflect upon when considering whether or not to have surgery. Conducted prior to the recent mesh pause in the UK, the article provides insights for current and future approaches to shared decision-making. METHODS: Qualitative in-depth interviews of 28 patients referred to secondary care for stress and mixed UI who were considering UI surgery. Participants were recruited from four urogynaecology clinics in the Midlands and South England, UK. Interviews were conducted in clinics, in patient homes, and by telephone. Data analysis was based on the constant comparative method. RESULTS: Participants' accounts comprised three key concerns: their experience of symptoms, the extent to which these impacted a variety of social roles and demands, and overcoming embarrassment. Accounts drew on individual circumstances, values, and concerns rather than objective or measurable criteria. In combination, these dimensions constituted a personal assessment of the severity of their UI and hence framed the extent to which women prioritized addressing their condition. CONCLUSIONS: Acknowledging women's personal accounts of UI shifts the concept of 'severity' beyond a medical definition to include what is important to patients themselves. Decision-making around elective surgery must endeavour to link medical information with women's own experiences and personal criteria, which often change in priority over time. We propose that this research provides insight into how the controversy around the use of mesh in the UK emerged. This study also suggests ways in which facilitating shared decision-making should be conducted in future.

Extended and standard duration weight-loss programme referrals for adults in primary care (WRAP): a randomised controlled trial.

BACKGROUND: Evidence exist that primary care referral to an open-group behavioural programme is an effective strategy for management of obesity, but little evidence on optimal intervention duration is available. We aimed to establish whether 52-week referral to an open-group weight-management programme would achieve greater weight loss and improvements in a range of health outcomes and be more cost-effective than the current practice of 12-week referrals. METHODS: In this non-blinded, parallel-group, randomised controlled trial, we recruited participants who were aged 18 years or older and had body-mass index (BMI) of 28 kg/m2 or higher from 23 primary care practices in England. Participants were randomly assigned (2:5:5) to brief advice and self-help materials, a weight-management programme (Weight Watchers) for 12 weeks, or the same weight-management programme for 52 weeks. We followed-up participants over 2 years. The primary outcome was weight at 1 year of follow-up, analysed with mixed-effects models according to intention-to-treat principles and adjusted for centre and baseline weight. In a hierarchical closed-testing procedure, we compared combined behavioural programme arms with brief intervention, then compared the 12-week programme and 52-week programme. We did a within-trial cost-effectiveness analysis using person-level data and modelled outcomes over a 25-year time horizon using microsimulation. This study is registered with Current Controlled Trials, number ISRCTN82857232. FINDINGS: Between Oct 18, 2012, and Feb 10, 2014, we enrolled 1269 participants. 1267 eligible participants were randomly assigned to the brief intervention (n=211), the 12-week programme (n=528), and the 52-week programme (n=528). Two participants in the 12-week programme had been found to be ineligible shortly after randomisation and were excluded from the analysis. 823 (65%) of 1267 participants completed an assessment at 1 year and 856 (68%) participants at 2 years. All eligible participants were included in the analyses. At 1 year, mean weight changes in the groups were -3·26 kg (brief intervention), -4·75 kg (12-week programme), and -6·76 kg (52-week programme). Participants in the behavioural programme lost more weight than those in the brief intervention (adjusted difference -2·71 kg, 95% CI -3·86 to -1·55; p<0·0001). The 52-week programme was more effective than the 12-week programme (-2·14 kg, -3·05 to -1·22; p<0·0001). Differences between groups were still significant at 2 years. No adverse events related to the intervention were reported. Over 2 years, the incremental cost-effectiveness ratio (ICER; compared with brief intervention) was £159 per kg lost for the 52-week programme and £91 per kg for the 12-week programme. Modelled over 25 years after baseline, the ICER for the 12-week programme was dominant compared with the brief intervention. The ICER for the 52-week programme was cost-effective compared with the brief intervention (£2394 per quality-adjusted life-year [QALY]) and the 12-week programme (£3804 per QALY). INTERPRETATION: For adults with overweight or obesity, referral to this open-group behavioural weight-loss programme for at least 12 weeks is more effective than brief advice and self-help materials. A 52-week programme produces greater weight loss and other clinical benefits than a 12-week programme and, although it costs more, modelling suggests that the 52-week programme is cost-effective in the longer term. FUNDING: National Prevention Research Initiative, Weight Watchers International (as part of an UK Medical Research Council Industrial Collaboration Award).

Falling into a routine: from habits to situated practices.

In line with the concept of 'nudging' people to change their behaviour, there has been increased attention on habit as a focus for psychologically-based health interventions. It is hoped that behaviours initiated by interventions not only become so regular that they are normalised into people's everyday lives, but that through repetition they may eventually become fixed and habitual. In this paper we draw on people's accounts of participating in a trial designed to encourage greater physical activity, and attend to the ways they describe their engagement with interventions within wider narratives of their everyday lives. In contrast to the idea that habit refers to automatic behaviour cued by external stimuli and governed by unconscious cognitive processes, our study describes how people identify many diverse elements that are felt to have equal significance in achieving a routine. Paradoxically, the sense of stability derives not from exact repetition, but from the ability for an assemblage of elements to be configured slightly differently each time. We consequently argue that attending to the diverse range of contextual elements bracketed off from interventions designed to be tested in trials, and the idea that continuity might emerge from variation, demands a reconceptualisation of the concept of habit adopted within many areas of current health psychology.

Learning to care: medical students' reported value and evaluation of palliative care teaching involving meeting patients and reflective writing.

BACKGROUND: Over recent years there has been an increase in teaching of both palliative care and reflective practice in UK medical schools. The palliative care teaching at the University of Cambridge School of Clinical Medicine is multi-faceted and involves students writing reflective essays after individually meeting patients approaching the end of life during their final year general practice and hospital medicine placements. This paper draws on two studies examining this teaching element to analyse what the students found valuable about it and to comment on the practice of meeting patients and subsequent reflective writing. METHODS: Two studies have explored students' perceptions of these course components. The first was a thematic analysis of 234 reflective essays from 123 students written in 2007-2008, including examining what students wrote about the exercise itself. The second project involved a semi-structured questionnaire that students completed anonymously; this paper reports on the free text elements of that study [sample size =107]. Since similar themes were found in both studies, the coding structures from each project were compared and combined, enabling triangulation of the findings around what the students found valuable from the palliative care teaching involving meeting patients and reflective writing. RESULTS: Overall, students reported that these components of the palliative care teaching are valuable. Four main themes were identified as aspects that students valued: (1) dedicated time with patients, (2) learning about wider elements of treatment and holistic care, (3) practicing communication skills, and (4) learning about themselves through reflective writing. Some students expressed a dislike for having to formally write a reflective essay. CONCLUSION: It is possible to arrange for all of the medical students to individually meet at least two patients receiving palliative or end of life care. Students found these encounters valuable and many wrote about the benefit of formally writing about these experiences. Students reported finding this model useful in widening their skill-set and understanding of palliative care.

From the concrete to the intangible: understanding the diverse experiences and impacts of new transport infrastructure.

BACKGROUND: Changes to the environment that support active travel have the potential to increase population physical activity. The Cambridgeshire Guided Busway is an example of such an intervention that provides new traffic-free infrastructure for walking, cycling and public transport. This qualitative investigation explored the diverse experiences of new transport infrastructure and its impacts on active travel behaviours. METHODS: Thirty-eight adult participants from the Commuting and Health in Cambridge natural experimental study were purposively selected according to their demographic and travel behaviour change characteristics and invited to participate in semi-structured interviews between February and June 2013. A mixed-method, following-a-thread approach was used to construct two contrasting vignettes (stories) to which the participants were asked to respond as part of the interviews. Inductive thematic qualitative analysis of the interview data was performed with the aid of QSR NVivo8. RESULTS: Perceptions of the busway's attributes were important in shaping responses to it. Some participants rarely considered the new transport infrastructure or described it as unappealing because of its inaccessibility or inconvenient routing. Others located more conveniently for access points experienced the new infrastructure as an attractive travel option. Likewise, the guided buses and adjacent path presented ambiguous spaces which were received in different ways, depending on travel preferences. While new features such as on board internet access or off-road cycling were appreciated, shortcomings such as overcrowded buses or a lack of path lighting were barriers to use. The process of adapting to the environmental change was discussed in terms of planning and trialling new behaviours. The establishment of the busway in commuting patterns appeared to be influenced by whether the anticipated benefits of change were realised. CONCLUSIONS: This study examined the diverse responses to an environmental intervention that may help to explain small or conflicting aggregate effects in quantitative outcome evaluation studies. Place and space features, including accessibility, convenience, pleasantness and safety relative to the alternative options were important for the acceptance of the busway. Our findings show how environmental change supporting active travel and public transport can encourage behaviour change for some people in certain circumstances.

Public attitudes towards pricing policies to change health-related behaviours: a UK focus group study.

BACKGROUND: Evidence supports the use of pricing interventions in achieving healthier behaviour at population level. The public acceptability of this strategy continues to be debated throughout Europe, Australasia and USA. We examined public attitudes towards, and beliefs about the acceptability of pricing policies to change health-related behaviours in the UK. The study explores what underlies ideas of acceptability, and in particular those values and beliefs that potentially compete with the evidence presented by policy-makers. METHODS: Twelve focus group discussions were held in the London area using a common protocol with visual and textual stimuli. Over 300,000 words of verbatim transcript were inductively coded and analyzed, and themes extracted using a constant comparative method. RESULTS: Attitudes towards pricing policies to change three behaviours (smoking, and excessive consumption of alcohol and food) to improve health outcomes, were unfavourable and acceptability was low. Three sets of beliefs appeared to underpin these attitudes: (i) pricing makes no difference to behaviour; (ii) government raises prices to generate income, not to achieve healthier behaviour and (iii) government is not trustworthy. These beliefs were evident in discussions of all types of health-related behaviour. CONCLUSIONS: The low acceptability of pricing interventions to achieve healthier behaviours in populations was linked among these responders to a set of beliefs indicating low trust in government. Acceptability might be increased if evidence regarding effectiveness came from trusted sources seen as independent of government and was supported by public involvement and hypothecated taxation.

Strengthening health system governance using health facility service charters: a mixed methods assessment of community experiences and perceptions in a district in Kenya.

BACKGROUND: Enhancing accountability in health systems is increasingly emphasised as crucial for improving the nature and quality of health service delivery worldwide and particularly in developing countries. Accountability mechanisms include, among others, health facilities committees, suggestion boxes, facility and patient charters. However, there is a dearth of information regarding the nature of and factors that influence the performance of accountability mechanisms, especially in developing countries. We examine community members' experiences of one such accountability mechanism, the health facility charter in Kericho District, Kenya. METHODS: A household survey was conducted in 2011 among 1,024 respondents (36% male, 64% female) aged 17 years and above stratified by health facility catchment area, situated in a division in Kericho District. In addition, sixteen focus group discussions were conducted with health facility users in the four health facility catchment areas. Quantitative data were analysed through frequency distributions and cross-tabulations. Qualitative data were transcribed and analysed using a thematic approach. RESULTS: The majority (65%) of household survey respondents had seen their local facility service charter, 84% of whom had read the information on the charter. Of these, 83% found the charter to be useful or very useful. According to the respondents, the charters provided useful information about the services offered and their costs, gave users a voice to curb potential overcharging and helped users plan their medical expenses before receiving the service. However, community members cited several challenges with using the charters: non-adherence to charter provisions by health workers; illegibility and language issues; lack of expenditure records; lack of time to read and understand them, often due to pressures around queuing; and socio-cultural limitations. CONCLUSION: Findings from this study suggest that improving the compliance of health facilities in districts across Kenya with regard to the implementation of the facility service charter is critical for accountability and community satisfaction with service delivery. To improve the compliance of health facilities, attention needs to be focused on mechanisms that help enforce official guidelines, address capacity gaps, and enhance public awareness of the charters and their use.

The contribution of media analysis to the evaluation of environmental interventions: the commuting and health in Cambridge study.

BACKGROUND: Media content can increase awareness of, and shape interactions with, public health interventions. As part of a natural experimental evaluation of the travel, physical activity and health impacts of the Cambridgeshire Guided Busway, we analysed print and social media discourse and interview data to understand the nature of new transport infrastructure and how it was experienced. METHODS: Newspaper articles were systematically retrieved from the LexisNexis database and tweets were identified from an online archive. Interviews were conducted as part of the larger evaluation study with 38 adults. Inductive thematic analysis was performed and comparisons were drawn between datasets. RESULTS: The findings are discussed in relation to five themes. First, an understanding of the intervention context and how the intervention was experienced was developed through accounts of events occurring pre and post the busway's opening. Second, the media captured the dynamic nature of the intervention. Third, the media constructed idealised portrayals of the anticipated busway which in some cases were contradicted by the impact of the busway on the existing context and people's lived experiences. Fourth, differential media coverage of the intervention components suggested that a lesser value was placed on promoting active travel compared with public transport. Lastly, interview data provided support for the hypothesis that the media increased awareness of the busway and served as a frame of reference for constructing expectations and comparing experiences. CONCLUSIONS: This analysis has contributed to the wider evaluation of the busway, helping to understand its nature and implementation and informing hypotheses about how the local population interact with the infrastructure by attending to the significance of representations in the media.

Weight loss referrals for adults in primary care (WRAP): protocol for a multi-centre randomised controlled trial comparing the clinical and cost-effectiveness of primary care referral to a commercial weight loss provider for 12 weeks, referral for 52 weeks, and a brief self-help intervention [ISRCTN82857232].

BACKGROUND: Recent trials demonstrate the acceptability and short term efficacy of primary care referral to a commercial weight loss provider for weight management. Commissioners now need information on the optimal duration of intervention and the longer term outcomes and cost effectiveness of such treatment to give best value for money. METHODS/DESIGN: This multicentre, randomised controlled trial with a parallel design will recruit 1200 overweight adults (BMI ≥28 kg/m2) through their primary care provider. They will be randomised in a 2:5:5 allocation to: Brief Intervention, Commercial Programme for 12 weeks, or Commercial Programme for 52 weeks. Participants will be followed up for two years, with assessments at 0, 3, 12 and 24 months. The sequential primary research questions are whether the CP interventions achieve significantly greater weight loss from baseline to 12 months than BI, and whether CP52 achieves significantly greater weight loss from baseline to 12 months than CP12. The primary outcomes will be an intention to treat analysis of between treatment differences in body weight at 12 months. Clinical effectiveness will be also be assessed by measures of weight, fat mass, and blood pressure at each time point and biochemical risk factors at 12 months. Self-report questionnaires will collect data on psychosocial factors associated with adherence, weight-loss and weight-loss maintenance. A within-trial and long-term cost-effectiveness analysis will be conducted from an NHS perspective. Qualitative methods will be used to examine the participant experience. DISCUSSION: The current trial compares the clinical and cost effectiveness of referral to a commercial provider with a brief intervention. This trial will specifically examine whether providing longer weight-loss treatment without altering content or intensity (12 months commercial referral vs. 12 weeks) leads to greater weight loss at one year and is sustained at 2 years. It will also evaluate the relative cost-effectiveness of the three interventions. This study has direct implications for primary care practice in the UK and will provide important information to inform the decisions of practitioners and commissioners about service provision. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82857232. Date registered: 15/10/2012.

From health behaviours to health practices: an introduction.

The concept of health behaviour has become ubiquitous in health-related research and intervention studies, as well as among policymakers. Developed from psychology, it is based on a number of key underlying assumptions that enable it to be integrated in an existing health research paradigm. However, by conceiving individual health behaviour as discrete, stable, homogeneous and measurable, many other aspects of health-related activities, in particular those relating to power and sociality, are excluded. As a consequence, any genuine contribution from medical sociology or related disciplines is, at best, limited. To counter this, it is proposed that reconceptualising what people do in terms of health practices, rather than health behaviour, captures the emergent and contingent properties of people's activities in particular situations. Rather than serving as a direct replacement term, and thus reproducing the same epistemological assumptions, it is argued that its very flexibility and capacity to articulate different theoretical orientations is likely to be its major strength.

Participants' explanatory model of being overweight and their experiences of 2 weight loss interventions.

PURPOSE: We explored participants' accounts of weight loss interventions to illuminate the reasons behind the greater weight loss observed among those attending a commercial program compared with those receiving standard care in a recent large-scale trial. We further wanted to examine how participants' general explanatory model of being overweight related to the 2 different interventions. METHODS: Our study was based on thematic analysis of semistructured telephone interviews with a purposeful sample of 16 female participants from the UK center of a randomized controlled trial of weight loss in primary care. RESULTS: The commercial provider delivered weight management in a nonmedical context, which mirrors how participants regard being overweight. Participants felt they needed support and motivation rather than education, and valued the ease of access and frequent contact the commercial provider offered. Some participants preferred individual level support with their primary care clinician, and all were positive about the opportunity to access support through the primary care setting. CONCLUSIONS: Primary care referral to a commercial weight loss program for people who do not require specific clinical care appears to be in accord with their general explanatory model about being overweight, offering motivation and support to lose weight outside a strictly medical context. This approach may not be effective or acceptable for everyone, however, and there are likely to be considerable variations in the explanatory models held. Findings support the argument that a range of evidence-based options for weight management should be available in primary care.

Testing a peer support intervention for people with type 2 diabetes: a pilot for a randomised controlled trial.

BACKGROUND: People with Type 2 diabetes face various psycho-social, self-management and clinical care issues and evidence is mixed whether support from others with diabetes, 'peer support', can help. We now describe a 2 month pilot study of different peer support interventions. METHODS: The intervention was informed by formative evaluation using semi-structured interviews with health professionals, community support groups and observation of diabetes education and support groups. Invitations to participate were mailed from 4 general practices and included a survey of barriers to care. Participants were randomized by practice to receive individual, group, combined (both individual and group) or no peer support. Evaluation included ethnographic observation, semi-structured interviews and questionnaires at baseline and post-intervention. RESULTS: Of 1,101 invited, 15% expressed an interest in participating in the pilot. Sufficient numbers volunteered to become peer supporters, although 50% of these (8/16) withdrew. Those in the pilot were similar to other patients, but were less likely to feel they knew enough about diabetes (60.8% vs 44.6% p = 0.035) and less likely to be happy with the diabetes education/care to date (75.4% vs 55.4% p = 0.013). Key issues identified were the need to recruit peer supporters directly rather than through clinicians, to address participant diabetes educational needs early and the potential for group sessions to have lower participation rates than 1:1 sessions. CONCLUSIONS: Recruitment to a full trial of peer support within the existing study design is feasible with some amendments. Attendance emerged as a key issue needing close monitoring and additional intervention during the trial.

Constructing denial as a disease object: accounts by medical students meeting dying patients.

As part of the general shift in contemporary healthcare from a focus on specific diseases to treating the whole person, doctors are now expected to be reflective and engage empathetically with patients. Yet, the context of end of life potentially confounds this commitment. Here we draw on the written submissions of UK medical students confronting dying patients to offer insight into a range of entangled issues. Although the exercise is designed to highlight the value of listening to patients and to encourage reflective practice, the experience of ultimately not being able to treat or cure frequently challenges the students' understanding of the central purpose of clinical care and their future role as doctors. Because they invariably draw on the notion of 'good death', whenever they have to make sense of patient behaviour deemed as irrational or obstructive the students employ the concept of 'denial' as a strategic category. In this context denial is referred to as a disease-like object that the students feel they can, and should, diagnose and treat. Such conceptual operations consequently illustrate a tension arising from trying to acknowledge the value of a whole-patient approach while simultaneously reproducing the emphasis placed on identifying those discrete elements that determine legitimate medical intervention.

Involving practice nurses in primary care research: the experience of multiple and competing demands.

AIM: This paper is a report of a study of the experiences of practice nurses delivering a complex research intervention in an exploratory randomized controlled trial in primary care. BACKGROUND: As practice nurses increasingly become involved in primary care research, it is important to understand not only what impact this may have on their existing role but also equally on what their potential contribution might be. METHOD: Fourteen of the 15 practice nurses involved in the delivery of a complex intervention were purposively sampled and interviewed in their workplace between June and October 2007. Interviews were audio-recorded, transcribed and analysed using a Framework Approach and NVivo software. Findings. Time influenced the nurses' engagement with the various aspects of the trial and meant that they constantly had to make judgments and decisions in response to the multiple agendas presented to them: they had to negotiate a range of competing loyalties between their professional clinical role, their role in the research and practice teams and their relationship with patients. The nurses' accounts consequently provide insight into the active role they played both in the trial process and the delivery of the complex intervention. CONCLUSION: The nurses were key to the delivery of the trial. If practice nurses are to develop a research role in their professional work, it is important to understand their perceptions and the impact such involvement has on them and their practice. Consideration of these factors is consequently valuable when developing research in primary care settings.

Tinkering and tailoring individual consultations: how practice nurses try to make cardiovascular risk communication meaningful.

AIMS AND OBJECTIVES: To explore the perspectives of practice nurses in their role of communicating cardiovascular risk to patients. BACKGROUND: Nurses in primary care have for some time been engaged in cardiovascular risk discussions with patients. With the recent introduction of the NHS Health Checks, the focus on this work is set to increase. DESIGN: Qualitative using a framework approach. METHODS: Two focus groups and 16 semi-structured interviews were conducted with nurses purposively sampled from those working in primary care. RESULTS: The nurses' accounts revealed the need to develop a relationship of trust and establish a level of relevance with each individual patient whilst discussing cardiovascular risk. Potential aspects of these discussions were as follows: working within a highly structured data-collecting task; time constraints and consideration of the individual's context. We used the idea of tailoring to describe how nurses navigate and constantly modify and pitch their approach for each patient they see in response to these constraints. CONCLUSION: We suggest that in order for risk to be made meaningful to patients, practice nurses recognise the need for such information to be embedded in the more reciprocal dynamics of nurse-patient consultations. From their perspective, success is often as much about not saying something, or saying it in a particular way, as saying anything accurately or consistently. RELEVANCE TO CLINICAL PRACTICE: For practice nurses to be instrumental in the successful delivery of health prevention policy initiatives such as the NHS Health Checks, it is important to acknowledge their views and perspectives in undertaking this work. This study suggests that the nurses recognised the need for further skills and a refinement of approach for those health professionals involved.

Placing death and dying: Making place at the end of life.

Over the last decade, policies in both the UK and many other countries have promoted the opportunity for patients at the end of life to be able to choose where to die. Central to this is the expectation that in most instances people would prefer to die at home, where they are more likely to feel most comfortable and less medicalised. In so doing, recording the preferred place of death and reducing the number of hospital deaths have become common measures of the overall quality of end of life care. We argue that as a consequence, what constitutes a desired or appropriate place is routinely defined in a very simple and static 'geographical' way, that is linked to conceptualising death as an unambiguous and discrete event that happens at a precise moment in time in a specific location. In contrast, we draw on 18 months of ethnographic fieldwork with two inner-London palliative care teams to describe the continual work staff do to make places suitable and appropriate for the processes of dying, rather than for a singular event. In this way, instead of 'place of death' merely defined in geographic terms, the palliative care staff attend to the much more dynamic relation between a patient and their location as they approach the end of their life. Central to this is an emphasis on dying as an open-ended process, and correspondingly place as a social space that reflects, and interacts with, living persons. We propose the term 'placing work' to capture these ongoing efforts as a patient's surroundings are continually altered and adjusted over time, and as a way to acknowledge this as a significant feature of the care given.

Multidisciplinary team meetings in palliative care: an ethnographic study.

OBJECTIVES: Multidisciplinary team meetings are a regular feature in the provision of palliative care, involving a range of professionals. Yet, their purpose and best format are not necessarily well understood or documented. This article describes how hospital and community-based palliative care multidisciplinary team meetings operate to elucidate some of their main values and offer an opportunity to share examples of good practice. METHODS: Ethnographic observations of over 70 multidisciplinary team meetings between May 2018 and January 2020 in hospital and community palliative care settings in intercity London. These observations were part of a larger study examining palliative care processes. Fieldnotes were thematically analysed. RESULTS: This article analyses how the meetings operated in terms of their setup, participants and general order of business. Meetings provided a space where patients, families and professionals could be cared for through regular discussions of service provision. CONCLUSIONS: Meetings served a variety of functions. Alongside discussing the more technical, clinical and practical aspects that are formally recognised aspects of the meetings, an additional core value was enabling affectual aspects of dealing with people who are dying to be acknowledged and processed collectively. Insight into how the meetings are structured and operate offer input for future practice.