Although preferences for both the depth and mode of information provision were variable amongst patients and families, they evaluated the quality of communication with staff primarily through inter-personal skills, rather than the prognostic accuracy of information that was imparted. However a need to balance professional uncertainty with patients’ and families’ needs for consistency in information was evident. Where patients were unlikely to MEK activity recover

from their stroke, Inhibitors,research,lifescience,medical then communication was perceived by staff to be both limited and difficult. “… you’ve actually got nothing to say to them. It’s not that you’re writing them off it’s just that your mind is elsewhere” “Yes, but you can see how people would perceive that as being “oh they’re withdrawing and just leaving us”” “… I have tried to at least acknowledge “I’m sorry your father’s so ill and obviously we won’t be seeing him now” or something like that. It actually is quite difficult Inhibitors,research,lifescience,medical to say. [3:35]” Whilst this may reflect the priorities within the stroke service, such as working to maximise patient recovery with rehabilitation as the predominant stroke service model, the potential negative impact of this difficulty on family members was recognised. “…she said the thing that she found very Inhibitors,research,lifescience,medical difficult when visiting her father was … when

it was clear that he wasn’t going to be alright,

they all ignored the family … she felt that Inhibitors,research,lifescience,medical suddenly they weren’t spoken to whereas they could see other families having lots of meetings and talking and they were almost embarrassing to have on the ward. Probably because the therapists didn’t know what to say or do. Inhibitors,research,lifescience,medical [3:29]” Early integration of palliative care Staff recognised the importance of integrating palliative care before the final stages of dying, addressing “the quality of life, not particularly end of life… even through the acute and the rehab phase, we would be looking at ‘not end of life’ palliative care” [1:4]. Emphasising that palliative care need not be end-of-life care was mirrored in the use of palliative approaches to resolve symptoms such as fatigue: Metalloexopeptidase “Because a lot of the patients who have the tiredness and fatigue are those who do really well in rehab, so you can’t say that they are in palliative care because they’re not. [3:54]” Extending palliative care earlier than the terminal stages of a dying trajectory characterised palliation as a positive intervention strategy, shifting the emphasis from “there’s nothing else we can do” whereas this is about “actually, there’s a lot we can do” [3:8]. Where a patient may be labelled as ‘palliative’ by some members of a stroke team, active interventions such as physiotherapy was still appropriate.