Community-based anticipatory prescribing during COVID-19: a qualitative study.

OBJECTIVES: To understand healthcare professionals' experiences of delivering anticipatory prescribing (AP) during the first wave of the UK COVID-19 pandemic. METHODS: Semistructured qualitative interviews were conducted with a purposive sample of 16 healthcare professionals involved in community palliative care. Data were analysed inductively using thematic analysis. RESULTS: Some of practitioners' fears about the pandemic's impact on delivering AP had not been realised during the first wave. Among patients with COVID-19 for whom community end-of-life care was deemed appropriate, deaths were perceived to be relatively easy to palliate with standard medications. These deaths were typically too rapid for AP to be appropriate or feasible. For non-COVID deaths, providing timely AP was more challenging: although community nurses and some palliative specialists continued to visit patients regularly, general practitioners did many fewer visits, moving abruptly to mainly remote consultations. This left some community nurses feeling undersupported, and prompted some palliative specialists to increase their direct involvement in AP. Several other changes were widely welcomed: collaboration to maintain drug supplies, adoption of online meetings and paperless practice, enhanced specialist helplines and a new policy allowing reuse of medication in care homes. The inclusion of more non-injectable options in AP protocols allowed clinicians to offer selected patients more choice, but few had yet done this in practice. No participants reported changing their prepandemic practice regarding administration of AP by lay caregivers. CONCLUSIONS: Accomplishing AP during a pandemic was challenging, requiring healthcare professionals to make rapid changes to their systems and practices. Some changes may produce lasting improvements.

The difference an end-of-life diagnosis makes: qualitative interviews with providers of community health care for frail older people.

BACKGROUND: Increasing numbers of people die of the frailty and multimorbidity associated with old age, often without receiving an end-of-life diagnosis. Compared to those with a single life-limiting condition such as cancer, frail older people are less likely to access adequate community care. To address this inequality, guidance for professional providers of community health care encourages them to make end-of-life diagnoses more often in such people. These diagnoses centre on prognosis, making them difficult to establish given the inherent unpredictability of age-related decline. This difficulty makes it important to ask how care provision is affected by not having an end-of-life diagnosis. AIM: To explore the role of an end-of-life diagnosis in shaping the provision of health care outside acute hospitals. DESIGN AND SETTING: Qualitative interviews with 19 healthcare providers from community-based settings, including nursing homes and out-of-hours services. METHOD: Semi-structured interviews (nine individual, three small group) were conducted. Data were analysed thematically and using constant comparison. RESULTS: In the participants' accounts, it was unusual and problematic to consider frail older people as candidates for end-of-life diagnosis. Participants talked of this diagnosis as being useful to them as care providers, helping them prioritise caring for people diagnosed as 'end-of-life' and enabling them to offer additional services. This prioritisation and additional help was identified as excluding people who die without an end-of-life diagnosis. CONCLUSION: End-of-life diagnosis is a first-class ticket to community care; people who die without such a diagnosis are potentially disadvantaged as regards care provision. Recognising this inequity should help policymakers and practitioners to mitigate it.

Rethinking decision-making in the context of preventive medication: How taking statins becomes "the right thing to do".

To understand decision-making in the context of longterm preventive medication, we explore the way "deciding" articulates with household medication practices and other everyday routines. Taking statins as a case study, we use qualitative data from interviews with 34 participants in the UK who had all been offered statins; 19 were currently taking them. Although all participants reference similar information about statins, the way they assemble and use their knowledge varies: there is a marked asymmetry between participants taking statins and those not taking them. Deliberation is a prominent feature of accounts of deciding not to take statins, but seldom visible within accounts of those taking them. Statin-takers emphasise that they have "no choice" about taking them, while non-takers stress the need to "think about it"; statin-takers' accounts prioritise biomedical tests over experiential knowledge, whereas non-takers sometimes prioritise experiential knowledge. All participants reference similar theoretical and experiential knowledge about side-effects, but whereas non-takers often use this knowledge to explain their decision to decline statins, those taking statins downplay both their own experiences and the likelihood that these are due to statins. To account for these asymmetries, we propose a model of decision-making in which deciding upon a course of action entails constructing a narrative presentation of medication use that frames it as "the right thing to do". This model helps us examine the two-way interactions between decision-making and the material practices through which regular medication gets taken, interactions often elided from accounts both of decision-making and of medication practice. In the context of longterm medication, the boundaries between "deciding" and "doing" are blurred; decision-making is situated within a web of collaborative, discursively-informed practices.

What is wrong with 'being a pill-taker'? The special case of statins.

In an interview study of decision-making about statins, many participants said they took pills regularly, yet described themselves as 'not really pill-takers'. This paper explores this paradox and its implications. The practice of pill-taking itself can constitute a challenge to the presentation of moral adequacy, beyond the potential for rendering stigmatised illnesses visible. Meeting this challenge involves a complex process of calibrating often-conflicting moral imperatives: to be concerned, but not too concerned, over one's health; to be informed, but not over-informed; and deferential but not over-deferential to medical expertise. This calibration reflects a broader tension between rival tropes: embracing medical progress and resisting medicalisation. Participants who take statins present them as unquestionably necessary; 'needing' pills, as opposed to choosing to take them, serves as a defence against the devalued identity of being a pill-taker. However, needing to take statins offers an additional threat to identity, because taking statins is widely perceived to be an alternative strategy to 'choosing a healthy lifestyle'. This perception underpins a responsibilising health promotion discourse that shapes and complicates the work participants do to avoid presenting themselves as 'pill-takers'. The salience of this discourse should be acknowledged where discussions of medicalisation use statins as an example.

Using Joint Interviews to Add Analytic Value.

Joint interviewing has been frequently used in health research, and is the subject of a growing methodological literature. We review this literature, and build on it by drawing on a case study of how people make decisions about taking statins. This highlights two ways in which a dyadic approach to joint interviewing can add analytic value compared with individual interviewing. First, the analysis of interaction within joint interviews can help to explicate tacit knowledge and to illuminate the range of often hard-to-access resources that are drawn upon in making decisions. Second, joint interviews mitigate some of the weaknesses of interviewing as a method for studying practices; we offer a cautious defense of the often-tacit assumption that the "naturalness" of joint interviews strengthens their credibility as the basis for analytic inferences. We suggest that joint interviews are a particularly appropriate method for studying complex shared practices such as making health decisions.

Using quantitative risk information in decisions about statins: a qualitative study in a community setting.

BACKGROUND: A large literature informs guidance for GPs about communicating quantitative risk information so as to facilitate shared decision making. However, relatively little has been written about how patients utilise such information in practice. AIM: To understand the role of quantitative risk information in patients' accounts of decisions about taking statins. DESIGN AND SETTING: This was a qualitative study, with participants recruited and interviewed in community settings. METHOD: Semi-structured interviews were conducted with 34 participants aged >50 years, all of whom had been offered statins. Data were analysed thematically, using elements of the constant comparative method. RESULTS: Interviewees drew frequently on numerical test results to explain their decisions about preventive medication. In contrast, they seldom mentioned quantitative risk information, and never offered it as a rationale for action. Test results were spoken of as objects of concern despite an often-explicit absence of understanding, so lack of understanding seems unlikely to explain the non-use of risk estimates. Preventive medication was seen as 'necessary' either to treat test results, or because of personalised, unequivocal advice from a doctor. CONCLUSION: This study's findings call into question the assumption that people will heed and use numerical risk information once they understand it; these data highlight the need to consider the ways in which different kinds of knowledge are used in practice in everyday contexts. There was little evidence from this study that understanding probabilistic risk information was a necessary or valued condition for making decisions about statin use.