Table 3.

Complex person-level themes leading to interacting mechanisms that influence human factors issues in out-of-hours palliative care

Themes	Exemplar quotations to support themes identified	SEIPS mapping
Frontline professionals commonly feared that the consequences of not admitting a patient to hospital or escalating investigations or disease-focused treatment would be personal blame	‘For the carer one of the critical questions is how will I know when they are actually about to die? Or what will I see, what will actually happen? And some cancers some conditions will manifest themselves in different ways, so for instance if I were to anticipate …I wouldn’t want to manage that and that could be …and coping afterwards you know, because that would be very stressful… but I don’t when people talk about preferred place of care they go into the A—the options, or that the hospitals sort’ve of thing or B—what each one then can offer, still so that they’re aware.’ (Professional) ‘One area with clinical practice which has changed dramatically in the last 24 months is sepsis and it’s not included in the advanced care plan it’s gonna happen that you become sceptic and everyone is now saying that and in out-of-hours cos I’ve seen in happen oh well if they become septic well their preferred place of care is at home but when they’re sceptic—call an ambulance.’ (Professional)	Person (healthcare professionals: emotional intelligence, meta-cognition, workplace culture, learning from prior experiences)
Patients and informal carers were reported to be regularly facing an impossible choice due to enormous differentials in the speed of response times of different services, that is, people were choosing between having any professional present quickly over having someone with the right expertise. Who was called by patients and informal carers was also shaped by previous experiences of who was most likely to respond.	‘We have a lot of calls because it’s quicker to get through to us than it is we have I mean we’ve worked our 8 hours that day so we’re doing an on-call and then doing another 8 hours literally we’re working solid through for 2 days and we have many calls at 3am, 5am you know because we’re quicker and that’s not a good thing is it at all?’ (Professional)	Person (patients and informal carers: psychological, cognitive and social factors)
Neither patients/informal carers nor professionals felt safe or supported to take calculated risks in line with patient priorities for care in the community	There’s a lady who’d had a severe stroke who was actually bed-bound for about 4 years Do Not Attempt Resuscitation (DNAR) end of life drugs, she was deteriorating, we sent a driver up, he [patient’s informal carer] still rang 999 and there was no way on earth that lady of ever being moved, she was hoist only, and she died in the ambulance—it’s unavoidable on times isn’t it?’ (Professional)	Person (patients, informal carers and healthcare professionals: psychological factors and learning from prior experiences)
The lack of pre-existing relationships between professionals within and across out-of-hours services meant there was a lack of trust, which in turn impinged on professional autonomy, giving and receiving advice, and lack of understanding of practical constraint on each other’s working practices	‘It took a couple of hours for someone from out-of-hours to see them, we were going that’s good! It’s pretty damn good that 2 hours, but you know it all depends what the family were expecting and actually 2 hours, I’m dialling 999 cos no one’s coming I’m on my own I don’t know what’s going on, they’re looking terrible… So there’s an issue of knowing what carer’s needs are and what their expectations are, and actually whether we’re able to meet them because otherwise the default will be 999. There were some issues around kind’ve expertise and knowledge and skills I don’t think it was a big as one of the other issues and the other final one which I suppose is around equipment 2 major issues were around catheters, simple as that, someone with terminal agitation where a catheter would’ve sorted it, for various reasons it wasn’t, and another where a patient had, had a catheter, it had come out at their request and then when it needed to go back in because it had been put in by frailty the Distrinct Nursing (DN) service, there wasn’t a catheter pack, so they couldn’t do it. So once again, different systems not, not connecting…’ (Professional)	Person (healthcare professionals: psychological and social factors in team working)
Apart from some doctors, professionals were uncertain of their authority to act on discussions around ceilings of care even in the presence of documented advance care plans, in part due to different policies and guidance in different organisations.	‘We had a 40 year old lady who we’d discharged from nursing home who had a detailed advanced care plan and they still admitted her at 8 o’clock in the morning you know we just sat and managed then to turn her around the following day and get her back out. So that was really disappointing because she could’ve died on route or what have you, fortunately she made it back to the home it was all the distress around that so there’s communication there around the nursing home and skills of the nursing staff and I think the knowledge and the understanding of the detail around the advanced care plan because when we looked into that they were saying oh we not everybody realised that the detail of that and therefore you know somebody like you say has probably panicked and thought oh my god we just need to send her in you know she was a little bit more short of breath, that was potentially imminently dying and it was just all very unfortunate.’ (Professional) ‘And that’s gone to the NMC (Nursing and Midwifery Council) saying why didn’t you start it? And she said well he was obviously dead it was not DNAR you have to go in and jump on his chest you cannot make that decision to say to stop it has to be a doctor.’ (Professional)	Person (healthcare professionals: meta-cognition, lack of empowerment, workplace cultures, learning from prior experiences)
Many professionals lacked understanding of the law regarding mental capacity and advance care planning and viewed ‘doing something’ as being by definition more defensible than what they perceived to be ‘doing nothing’ even though the latter was often in fact not nothing but taking action to provide appropriate symptom control and basic care	‘Because they’ll say oh yeah we’ve got a DNAR, but it doesn’t mean to say that they’re not gonna be actively treated up to the point of arrest and the number of times when you’re saying to people in nursing homes well are they for admission or are they treatment within their home? And they can’t answer you most of the time and they’re making calls in the middle of the night to relatives to ask then do you want them to go in or not? But we can’t take that as a legal requirement because we, because nobody’s had the discussion properly and put it in writing, so some of it is to do with the advanced planning really. It seems to be lacking…so by the time our GP’s or our nurses are coming in the middle of the night you’ve got to follow with what’s before you and half of the times when I’ve driven like say and I don’t want to send this person in, but there is nothing there to stop me.’ (Professional) ‘The COPD’s [Chronic Obstructive Pulmonary Disease, COPD] and the dementia’s and things like that, because the disease trajectory is difficult to work out you can have somebody who’s had a DNAR and they are in place for 4 years but it’s never been updated and therefore how can you make a decision on something that was put on 4 years ago. If it’s not been updated on an electronic system or anything.’ (Professional)	Person (healthcare professionals: cognitive and psychological factors)

SEIPS, Systems Engineering Initiative for Patient Safety.