An inquiry into what organised difficult advance care planning conversations in a Scottish Residential Care Home using Institutional Ethnography

This paper provides an institutional ethnographic analysis of how discussions and advance decisions about serious illness, hospital admission and Do Not Attempt Cardio Pulmonary Resuscitation forms have been systematically placed into the hands of Senior Social Care Workers (SSCWs) in Residential Care Homes (RCH) with insufficient support from healthcare professionals for those important healthcare decisions to be made safely and/or effectively. RCHs are care settings where there are no on-site nurses and access to hospital and/or community doctors and nurses is limited. The paper follows clues found in data vignettes of day-to-day working practices that had been constructed from interviews with SSCWs (n=4) and others (n=6) whose work shaped what happened in the RCH. This careful detective work uncovered the empirical links that tied SSCWs work into a complex web of socially organised institutional practices and purposes through the use of powerful organising texts such as national and local policies, care planning documents and audit forms. The paper concludes that while SSCWs conversations about serious illness, hospital admission and DNACPR forms were out of alignment with national polices and with what SSCWs thought was appropriate they were not simply isolated incidences of poor practice by incompetent staff. This is because these conversations pulled SSCWs (and others) into a complex web of institutional practices that were infused with powerful political and fiscal drives to reduce government spending on the care of older adults - which had little to do with the actual care needs of RCH residents or the support needs of RCH staff. The analysis reported in this paper provides insight into necessary policy changes. It also offers a different account of care home deaths than is typically represented in the professional literature.