Similar findings have been found in a study of district nurses’ perceptions of their role in palliative care [19] which revealed that district nurses feel that they have a central role in the provision of such care to patients at home which is undervalued

and poorly recognized by others. While community nurses perceived that they have a crucial role in ‘opening the door’ to ACP with patients they were concerned to Inhibitors,research,lifescience,medical time such discussions sensitively, against a cultural backdrop that does not encourage open discussion of death. One aspect to the issue of timing related to a concern that, in addressing ACP issues with patients, nurses risk being out of step with GPs and hospital doctors, whom they perceive are either yet to afford ACP a high priority or do not feel comfortable about raising it until very late in Inhibitors,research,lifescience,medical a disease trajectory. Horne et al [20] have described how nurses working to develop ACP practice with patients with lung cancer strove to identify a ‘window of opportunity’ when ACP issues can be raised with patients but were worried that any development of their practice with such patients may not be complemented by the approach of other staff involved in patient care. A later study of GPs and community

nurses found that there was a tendency for both to wait until patients raised issues of relevance to ACP [22]. More research Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical is needed to explore how community nurses and indeed other health care staff initiate ACP discussions. This study has shown that traditional power differentials between nursing and medicine can pose a barrier to the team working and discussion necessary for the implementation of ACP. A literature review about inter-professional team working in Apoptosis antagonist primary and community

care has highlighted the need for clear, shared goals to be established to enable effective team working [29]; this is a particularly pertinent issue in managing transitions to palliative Inhibitors,research,lifescience,medical care for patients in the community approaching the end of life. In addition, nurses perceived risks of ACP becoming a bureaucratic Calpain ‘tick box’ exercise as a result of a culture of managerialism with the potential effect perceived of subverting good practice in end-of-life care. A similar and broader trend has been described in a seminal paper about the ‘routinisation of hospice’ [30]. Avoiding this requires policy makers and clinical managers to appreciate that guidance and protocols for ACP must be subject to professional judgment about their use. This will involve professionals engaging in an ethical analysis of the risk and benefits of ACP for any particular person, using the principles of biomedical ethics (autonomy, beneficence, non- maleficence and justice) [31]. Indeed, nurses perceived a range of moral and ethical concerns to be associated with ACP [32].