Explaining how medical doctors learn about and understand the approach to the end-of-life in the workplace

Abstract

Background For patients approaching the end-of-life, treatments with life-prolonging intent can be futile, wasteful, and harmful. Equally, harm may be caused by prematurely treating patients as if they are dying. In order to provide a high standard of care, and align with clinical guidance, doctors must appropriately discern when a patient is approaching the end-of-life. This thesis takes the necessary and novel step of developing an explanation for how medical doctors learn about and understand the approach to the end-of-life in the workplace. Research aims 1. To examine how the approach to the end-of-life is conceptualised by medical doctors; 2. To explore experiences and understandings of doctors learning to care for patients at the approach to the end-of-life, including factors which provide barriers to learning; 3. To develop a theoretical explanation of the learning of doctors about the approach to the end-of-life. Methodology and methods Taking a critical realist ontological position, this thesis considers what causal mechanisms influence doctors learning about and understanding the approach to the end-of-life. Data were generated through complementary methods: • Scoping study and qualitative content analysis (QCA) of medical literature (2006- 2016) to examine established conceptions about the approach to the end-of-life among UK medical doctors; • Thematic analysis (TA) of data from semi-structured interviews with newly graduated (foundation) doctors to explore development of understandings of the approach to the end-of-life, and influences on this development and learning; • Examination of the findings through the lens of a socio-material epistemological framework – Cultural Historical Activity Theory (CHAT) – to theorise how interacting factors influence the learner/practitioner in a complex environment. Results QCA of two hundred and sixty-nine included documents identified that there is no single shared understanding of the approach to the end-of-life among doctors. TA of data from fifteen interviews with foundation doctors indicates that care of the patient approaching the end-of-life is a central aspect of their role and is learned about after leaving medical school, beginning practice, becoming integrated into the workplace. Both the literature and interview data indicate the approach to the end-of-life is not understood as a discrete entity but is constructed dynamically in relation to the patient, their disease, potential treatments and implications of these treatments, from the perspective of the practicing doctor. CHAT allowed for consideration of this practice-based learning as systems of activity, and identification of where contradictions within and between each activity system act as barriers to learning and practice. Discussion and conclusions The results have significant implications for educators and policy makers: understandings of the approach to the end-of-life are not gained in advance of practice (i.e. in medical schools). Instead, understandings are dynamically constructed by doctors in their practice. Improving the doctor’s workplace by overcoming tensions and challenges identified in this thesis should be focuses for intervention to improve learning and care for these patients in the future.