Using an end-of-life care pathway in acute stroke: a mixed methods study of decision-making and care experiences

Background: The evidence base on end-of-life care in acute stroke is limited, particularly with regard to recognising dying and related decision-making. There is also limited evidence to support the use of end-of-life care pathways (standardised care plans) for patients who are dying after stroke. Aim: This study aimed to explore the clinical decision-making involved in placing patients on an end-of-life care pathway, evaluate predictors of care pathway use, and investigate the role of families in decision-making. The study also aimed to examine experiences of end-of-life care pathway use for stroke patients, their relatives and the multi-disciplinary health care team. Methods: A mixed methods design was adopted. Data were collected in four Scottish acute stroke units. Case-notes were identified prospectively from 100 consecutive stroke deaths and reviewed. Multivariate analysis was performed on case-note data. Semi-structured interviews were conducted with 17 relatives of stroke decedents and 23 healthcare professionals, using a modified grounded theory approach to collect and analyse data. The VOICES survey tool was also administered to the bereaved relatives and data were analysed using descriptive statistics and thematic analysis of free-text responses. Results: Relatives often played an important role in influencing aspects of end-of-life care, including decisions to use an end-of-life care pathway. Some relatives experienced enduring distress with their perceived responsibility for care decisions. Relatives felt unprepared for and were distressed by prolonged dying processes, which were often associated with severe dysphagia. Pro-active information-giving by staff was reported as supportive by relatives. Healthcare professionals generally avoided discussing place of care with families. Decisions to use an end-of-life care pathway were not predicted by patients’ demographic characteristics; decisions were generally made in consultation with families and the extended health care team, and were made within regular working hours. Conclusion: Distressing stroke-related issues were more prominent in participants’ accounts than concerns with the end-of-life care pathway used. Relatives sometimes perceived themselves as responsible for important clinical decisions. Witnessing prolonged dying processes was difficult for healthcare professionals and families, particularly in relation to the management of persistent major swallowing difficulties.

An explanation of consumer trust recovery in a food retailer

An organization trusted by consumers enjoys a number of benefits. Unfortunately, instances of trust-damaging events involving organizations happen often. Damaged consumer trust in an organization has numerous negative consequences for the organization and for consumers. Currently, there is a paucity of theory about consumer trust recovery. So, understanding why and how consumer trust recovery occurs is timely, and theoretically and practically relevant. However, the findings from this study suggest that we need to distinguish between two kinds of consumer trust recovery. The first (I call it unconscious consumer trust recovery) refers to trust recovery that occurs without the consumer being fully conscious of it. In other words, a consumer is aware of their damaged trust during the scandal, but is not aware that their trust in the organization has improved. The consumer does not think about his or her recovered trust, just as they did not think about their level of trust before the scandal. The consumer trust is habitual. The second (I call it conscious consumer trust recovery) refers to an improvement in damaged trust where the consumer is fully conscious of their trust recovery. In other words, in conscious trust recovery the consumer is aware that the scandal damaged their trust in the organization. Also, after the scandal, in contrast to unconscious trust recovery, in conscious trust recovery the consumer is also fully aware that he trusts the organization as much or more than during the scandal. My aim is to inductively develop a theory explaining each type of consumer trust recovery. To do so, I use Charmazian grounded theory methodology, because this methodology is developed for theory-building from data and is aligned with the philosophical underpinnings of this study. The empirical context for this study is the meat adulteration scandal (“the horse meat scandal”) in 2013 in the UK. I collect and analyse empirical data about both types of trust recovery in an organization from 31 consumers that experienced both types. My analysis shows that when consumers perceive the scandal as less important, they experience unconscious trust recovery. This happens because the reduced importance of the scandal leads to a shift in consumers’ attention, which in turn leads to their inattentiveness to the scandal. Consumer inattentiveness is an immediate antecedent of unconscious trust recovery. Conscious consumer trust recovery occurs because consumers see cues indicating to them that the food retailer has improved product control systems, which in turn leads to consumer perceptions of the organization’s renewed ability. Consumer perception of renewed ability is an immediate antecedent of their conscious trust recovery. My findings lead me to make three main theoretical contributions to the theory of trust recovery in general and to consumer trust recovery in particular. The first contribution lies in showing that there are two types of consumer trust recovery in an organization, not one, as previously conceptualised, and that the same consumers can experience both types. The second contribution is a theory of unconscious consumer trust recovery in an organization that involves three concepts: consumers’ perceived importance of the scandal, consumers’ shift of attention, and consumer inattentiveness. The third contribution is the finding that conscious recovery of consumer trust occurs even when existing theory of trust recovery would predict that it would not. This study can help managers aiming to repair consumer trust in an organization by identifying a set of antecedents and underlying mechanisms that can guide such trust repair.