Managing Death: Navigating and reconciling divergent logics in end of life care
Arrival from 12 noon. Seminar starts at 12.15pm and ends at 1.15pm.
Tea, coffee and sandwiches provided (please register if you want these, and to guarantee a seat!)
Simon Bailey, Research Fellow, MBS
Damian Hodgson, Professor of Organisational Analysis, MBS
In recent years, the question of how care of the dying is best organised have gained a new prominence (Gawande, 2014), driven in the UK by both policy directives (DH, 2008) and by media furores over the use or abuse of care pathways (Neuberger, 2013). Underlying these debates are persistent questions regarding what constitutes ‘good care’ at the end of life (Ellershaw et al, 2010) - where this should occur, how best to involve patients and carers in decisions regarding end of life care, and how to control (i.e. reduce) the cost of this care. The prevalent discourse in this field is that the failure to ‘manage’ death frequently leads to ‘unnecessary’ and intrusive medical procedures (Gott et al, 2013), which are unreflexively initiated, typically in hospital settings, to extend life at any cost. Such an ‘unmanaged’ death can be more distressing and painful for both the person dying and their family. At the same time, it has not gone unnoticed in straightened financial times for the NHS that such deaths are significantly more expensive than are deaths which are ‘managed’, using a planned care pathway, through which patients can often be supported to die ‘at home’ (NEoLCIN, 2012). It has also been claimed that patient and carers themselves increasingly would prefer, or should prefer, a managed death at home (Balducci, 2012).
Debates over good end of life care, then, rely on differing understandings and logics (Goodrick and Reay, 2011; McDonald et al, 2013) of what would constitute ‘a good death’ (Griggs, 2002; Costello, 2006; Goldsteen et al, 2006) and who is best placed to deliver this (Walshe et al, 2008). One way to frame these debates would be to see these as reflecting a wider tension in Western healthcare systems, between what Annmarie Mol terms a logic of choice versus a logic of care (Mol, 2008). The consensus among specialists which has prevailed in end of life care policy is that the best solution is to make it possible for people to die in their ‘usual place of residence’, which is assumed to be more likely to constitute ‘a good death’; which is at the same time a less expensive and more controlled death. The challenge in part is then to inform and reassure patients so that this becomes their choice (Munday et al, 2007). Achieving this requires the smooth interaction of numerous different professionals from across primary, secondary and community care as well as social services (Wye et al, 2012). However, concluding that this is another area merely requiring ‘improved integration’ between practitioners fails to account for the moral uncertainties and divergent logics at play here, which shape individuals’ capacity to act in unpredictable ways (Candrian, 2013).
Drawing on a 12 month mixed-methods study conducted across three areas of Greater Manchester, we seek to examine how the tensions between different logics play out in the design and delivery of end of life care aimed to facilitate deaths outside of hospital settings. Using interviews and focus groups involving GPs, hospital consultants, nurses, commissioners, care home managers and healthcare managers, we examine the different ways in which end of life care is framed in the accounts of interviewees. This approach serves to shed light on the discursive relations which shape legitimate responses to end of life care, and the embedded hierarchies of authority which limit the possible (collective) action of professionals. In conclusion we draw on counter examples to explore the conditions through which certain professions manage extend their capacity to act, from which we derive some considerations for future research and practice in this area.
About the speakers
Damian Hodgson is Professor of Organisational Analysis at Manchester Business School and joint lead of the Primary Care theme of CLAHRC Greater Manchester. His research centres on issues of power, knowledge, identity and control in complex organisations and the management of experts/professionals. He is lead researcher on several projects within the Community Services and Primary Care themes in CLAHRC-GM, including the End of Life Care Pathways Mapping project, the Primary Care Demonstrator Evaluation and Chronic Kidney Disease research programme.
Simon Bailey is a research fellow for CLAHRC Greater Manchester, based at Manchester Business School. His research interests are in the critical study of management and organisations, exploring relations of power, knowledge and subjectivity within public organisations, with a particular focus on healthcare. His research is strongly interdisciplinary, contributing to research and theory in organisation studies, sociology of work, medical sociology, childhood and education. He published his first book, ‘Exploring ADHD’, with Routledge in 2013, and since 2010 has been involved in a research-theatre collaborative, whose first production, ‘Inside out of Mind’, completed a national tour in 2015.
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