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Abstract
Objective To summarise evidence on how multidisciplinary team (MDTs) make decisions about identification of imminently dying patients.
Design Scoping review.
Setting Any clinical setting providing care for imminently dying patients, excluding studies conducted solely in acute care settings.
Data sources The databases AMED, CINAHL, Embase, MEDLINE, PsychINFO and Web of Science were searched from inception to May 2021.
Included studies presented original study data written in English and reported on the process or content of MDT discussions about identifying imminently dying adult patients.
Results 40 studies were included in the review. Studies were primarily conducted using interviews and qualitative analysis of themes.
MDT members involved in decision-making were usually doctors and nurses. Some decisions focused on professionals recognising that patients were dying, other decisions focused on initiating specific end-of-life care pathways or clarifying care goals. Most decisions provided evidence for a partial collaborative approach, with information-sharing being more common than joint decision-making. Issues with decision-making included disagreement between staff members and the fact that doctors were often regarded as final or sole decision-makers.
Conclusions Prognostic decision-making was often not the main focus of included studies. Based on review findings, research explicitly focusing on MDT prognostication by analysing team discussions is needed. The role of allied and other types of healthcare professionals in prognostication needs further investigation as well. A focus on specialist palliative care settings is also necessary.
- adult palliative care
- organisation of health services
- health services administration & management
- palliative care
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- adult palliative care
- organisation of health services
- health services administration & management
- palliative care
Strengths and limitations of this study
The present scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline for Scoping Reviews.
Multiple databases were searched, and a broad search strategy was applied to identify relevant literature.
An inclusive screening approach was adopted to ensure that relevant papers and data were not excluded.
Two reviewers independently screened publications for eligibility and data extraction, with disagreements resolved through consensus in the study team.
The lack of detailed data on the decision-making process yielded discussions within the study team about whether excerpts specifically concerned identification of imminently dying patients and whether the included professionals constituted a multidisciplinary team.
Background
The term ‘end-of-life’ is often used to refer to patients who are approaching the last year of life.1 When patients are within the last days or hours of life, they are more appropriately referred to as ‘imminently dying’.2 3 Identification of end-of life and imminently dying patients, and more generally estimating patients’ length of survival, can guide clinicians to use relevant care pathways. Studies have shown that patients, their carers and clinicians, all value accurate prognostic information.4–9 Information on how much time a patient has left to live can help patients and family members to make important decisions, feel prepared for death, prioritise commitments and plan treatment and care in the hospital or community.10 However, clinicians’ survival estimates are often inaccurate and overoptimistic.11–14 Despite clinicians’ challenges with estimating accurate length of survival, studies show that a slight improvement in prognostic accuracy can be seen through seeking a second opinion15 or through a multidisciplinary team (MDT) discussion.16–18
MDTs include members from different healthcare and non-healthcare professions and disciplines, who work together to provide and improve care for patients.19 20 Team members can include professionals such as doctors, nurses, occupational therapists, physiotherapists, speech and language therapists, chaplains and social workers, where some professionals are part of ongoing patient care and others may be involved on an ad hoc basis to meet specific needs.21 The MDT facilitates communication between different professionals, which can improve the working environment and provide learning and development opportunities.22 Decisions about patient treatment and care may be based on reviews of clinical documentation such as case notes, test results and diagnostic imaging.23 MDTs are common in care of the elderly, mental health, oncology and other services,24 and are an essential feature of holistic palliative care provision.25
An independent report into shortcomings of the Liverpool Care Pathway for the Dying Patient recommended that research should be undertaken to better identify imminently dying patients and to understand how MDTs make prognostic decisions and communicate uncertainty.26 Previous reviews reporting on MDTs in palliative care have focused on assessing their outcomes and efficiency27–29 rather than their prognostic decision-making processes. The aim of this scoping review was to explore how MDTs make decisions about whether patients are imminently dying. In addition, the review includes a closer investigation of the specialist palliative care setting to identify any established processes that could potentially be recommended for other settings.
Aim
The review aimed to identify how the decision-making process is reported in the literature in order to highlight significant gaps in evidence. The primary research question was:
What is known, from the existing MDT decision-making literature, about the identification of patients who are dying?
The secondary research questions were:
How is the decision-making process described in the literature?
What are the characteristics of decision-making about the identification of dying patients in specialist palliative care settings?
Are there any decision-making barriers, opportunities and/or recommendations?
Methods
A scoping review was conducted to address study aims. This type of review is appropriate for highlighting significant gaps in the evidence30 31 and provides a useful alternative to standard systematic reviews when clarification around concepts or theory is required.32 Scoping reviews are systematic in their approach but a key difference between scoping reviews and systematic reviews is that they have a broader research question than traditional systematic reviews and will therefore often involve more expansive inclusion criteria.32 Moreover, scoping reviews do not usually involve critical appraisal of the evidence, instead the focus is on providing an overview of the evidence.32 In this way, scoping reviews can identify areas for future systematic reviews or other types of evidence synthesis.33
The review was conducted using the theoretical framework for scoping reviews introduced by Arksey and O'Malley,30 and by following current guidelines within the field.33 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline for Scoping Reviews34 was followed. The protocol for the review was registered with the Open Science Framework on 26th August 2020 (www.osf.io/sv5te).
Search
Databases were searched from inception until 18th May 2021 and comprised the following six electronic databases: AMED, CINAHL, Embase, MEDLINE, PsycINFO and Web of Science. No date limit was applied in order to capture the breadth of literature. Grey Literature Report (www.greylit.org) and Open Grey (www.opengrey.eu) were also searched to identify further potentially eligible studies. Additionally, forward and backward citation searches were undertaken.
The search strategy comprised four domains: (1) palliative population; (2) MDTs; (3) decision-making and (4) prognosis/dying (see online supplemental file 1). Since the aim was to provide an overview of the field and identify knowledge gaps, a highly sensitive search strategy was used, using synonyms and similar concepts for keywords. Search terms were tailored to each database’s search engine and terminology.
Supplemental material
Eligibility criteria
The following eligibility criteria were applied during the screening process. No studies were excluded on the basis of study design.
Inclusion criteria
English-language full-text papers.
Studies presenting original data (either qualitative or quantitative) related to MDT decision-making about the identification of patients who are imminently dying.
Studies reporting on the process and/or content of MDT meetings or discussions, either by studying the team as a whole, or individual team members (e.g., surveys of doctors’ and nurses’ individual reflections on MDT communication).
Exclusion criteria
Non full-text and non-peer-reviewed publications (e.g., conference, poster and meeting abstracts, dissertations and theses).
Studies involving children (subjects under 18 years old).
Studies conducted exclusively in intensive care units (ICUs), emergency departments or similar acute care settings.
Teams that did not consist of members with different professional roles.
Studies concerning patients who were not imminently dying (estimated length of survival longer than hours/days).
Studies exploring how team members interacted with patients and/or family carers rather than between themselves.
Studies concerning clinicians’ reflections on MDT discussions in which they did not participate (e.g., medical directors’ reflections on MDT working).
Studies conducted exclusively in acute care were excluded because prognosticating imminent death in these settings was deemed likely to involve significantly different processes from prognosticating in non-acute settings and to fall outside of the scope of the review. In this review, we define acute care settings as ICUs, emergency departments and similar acute settings. In these acute care settings, decisions often need to be made quickly and there may be little time for MDT deliberation. Prognostication of imminent death in ICUs, for example, may be complicated by decisions about withdrawal of immediately life sustaining therapies (e.g., intubation). Studies conducted in both acute and non-acute care settings were deemed eligible for inclusion.
The definition of what constituted an MDT for the purpose of prognostic decision-making was kept broad to avoid excluding potentially relevant literature. Studies were deemed eligible if they reported on decision-making between at least two professionals with different roles or disciplines.
Selection of sources of evidence
Publications were initially screened by title and abstract by two reviewers independently (AB and LO/A-RS/LM). If reviewers did not agree on eligibility of a publication, or if eligibility was unclear, the paper was retained for further scrutiny. The second round of screening involved review of full-text papers, which was also done independently by two reviewers (AB and LO). Any remaining disagreements were resolved through consensus in the study team.
Data extraction and analysis
Data extraction was completed independently by two reviewers (AB and LO). Extracted data included paper characteristics (authors, year of publication and country of origin), study aims, methods of data collection, analysis and study design (clinical setting, patient type, number and profession of participants).
Decisions were identified either by direct quotes from MDT members or authors’ descriptions of decisions.35 These data are referred to as ‘excerpts’. Decision-making characteristics were extracted for each decision reported in included papers. Characteristics included staff members involved in the decision, topic of the decision and description of the decision-making process.
There is an overlap between recognising dying, managing dying and treating acute illness. The process by which dying is recognised cannot always be clearly separated from other processes of clinical care which take place at the same time.36 Decisions were categorised according to the topic of the decision being discussed by the MDT. All excerpts involved MDT members’ decisions about identifying imminent death, however some also related to other aspects of care.
After identifying relevant decision-making characteristics, it was decided to categorise decision-making processes according to the degree to which they were deemed to be collaborative (showing full, partial or no collaboration). Judgements about the level of collaboration were based on whether excerpts provided evidence of information-sharing between staff and/or evidence of joint decision-making. In addition, emerging subthemes were identified when excerpts were categorised.
Additionally, recommendations and barriers reported in the study implications section of included papers were extracted.
Paper excerpts and themes/categorisations were extracted and managed using Microsoft Word. A narrative review approach has been applied, resulting in a narrative synthesis of the scoped research.
Patient and public involvement
Patients and/or members of the public were not involved in the design, conduct, reporting or dissemination plans of this review.
Results
The search initially identified 10592 publications which reduced to 8327 after duplicate records were removed. Title and abstract screening yielded 1351 potentially eligible publications. After full-text screening, 25 papers were initially identified for inclusion in the review. An additional 15 papers were identified following backward and forward citation searches, resulting in a total of 40 papers (figure 1). These papers yielded 67 excerpts relevant to MDT decision-making about identification of patients who were imminently dying.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram of study selection.
Characteristics of included studies
Key characteristics of the included studies are shown in table 1.
Study characteristics
Studies were conducted in ten countries: UK (n=14),37–50 Australia (n=6),51–56 USA (n=5),57–61 Sweden (n=5),62–66 Canada (n=4),67–70 New Zealand (n=2),71 72 Saudi Arabia (n=1),73 the Netherlands (n=1),74 Thailand (n=1)75 and China (n=1).76 Years of publication ranged from 2001 to 2021.
Data were mostly collected using qualitative approaches. Interviews were completed in 27 of the included studies; either as sole method of data collection (n=15)39 40 45 46 51 55 57 59 64 66–70 76 or alongside other methods. These included focus groups,37 41 47 48 50 62 collaborative learning groups,42 observations,37 38 42 43 49 54 74 field notes,38 42 43 63 review of case notes,37 documentary analysis42 and questionnaires.42 Studies reported using focus groups alone44 56 58 60 61 72 or in combination with surveys.71 Other studies collected data through reflective journaling and field notes73; free-text comments of questionnaires65; retrospective observational audit of patient deaths52 and reviewing patients’ medical records.53
Methods of data analysis were qualitative, and most often involved identifying themes. Most studies reported having conducted a general analysis of themes (n=22).37–43 45–49 55 60 61 64 67 68 70 72–74 Content analysis51–54 56 57 62 65 66 76 and thematic analysis involving specific frameworks were conducted as well.44 50 58 59 69 75 Other methods included narrative analysis,63 basic descriptive analysis71 and matrix analysis.59
The majority of studies were conducted in hospital settings (n=28).37 38 40 41 44 45 47–49 51–56 58 59 63–71 73 75 76 Other clinical settings included care homes (n=10),42 43 50 57 60–62 67 72 74 hospices (n=5),39 41 46 48 55 community (n=5)40 50 55 59 76 and primary care (n=4).40 41 48 50
Nurses were most often included in the sample under investigation. 11 studies included only doctors and nurses as part of the sample.38–40 44–46 62 65 68 70 76 Ten studies included doctors, nurses and other types of healthcare professionals.41 42 47 48 50 51 61 67 71 74 Three studies included only nurses and other healthcare professionals.43 56 60 13 studies focused on a particular group of professionals such as nurses,49 54 55 63 64 66 69 73 75 doctors,57 59 physician assistants58 or healthcare assistants.72 Two studies included any type of clinician who wrote an entry in patients’ medical records.52 53 Lastly, one study did not specify the professionals involved but study quotes came from doctors and nurses.37
MDT prognostic decision-making
Among included studies, 67 excerpts related to MDT decision-making processes about whether a patient was imminently dying (see online supplemental file 2). The decision-making information came from interview quotes, free-text comments, medical notes or/and from authors’ summarised descriptions of data. Decision-making characteristics are shown in table 2.
Supplemental material
Decision-making characteristics
Staff members involved in decision-making
Various staff members were involved in decision-making (table 2). Included studies most often reported decisions involving nurses and doctors.38–41 43–47 49 51 52 54–56 62–71 73 75 Evidence showed that decision-making between different types of nurses62 and between doctors with different specialties48 59 occurred as well. Decision-making between doctors and ‘other’ or ‘unspecified’ staff members39 50 53 57 58 74 and between nurses and other staff groups37 39 40 42 69 70 72 76 also occurred. Allied healthcare professionals were reported as being involved in the decision-making in four of the included studies.51 53 67 69 Two studies reported how other specified healthcare professionals such as carers and physician assistants were involved in decision-making.42 58
Topic of decisions
Almost half of the decisions (n=32) involved healthcare professionals recognising or judging whether a patient was dying,40 42–51 53–55 59–61 67 69–72 76 which included descriptions such as whether the patient was at the end-of-life or was considered ‘palliative’. Formulations also included whether a palliative approach should be initiated and how staff recognised changes related to patient deterioration.
However, identifying dying was usually not the only or even the main decision being discussed by the MDT. Other issues, related to the identification of dying patients, were deciding whether to use a specific end-of-life care pathway (n=13)39 43 45 51 56 62 71 74; discussing or clarifying patients’ goals of care (n=9)37 41 52 53 58 69 70 75; making do not resuscitate (DNR) orders (n=5)38 40 65 66 73; whether specific (aggressive) treatments were appropriate and/or should be continued (n=4)63 68 69 75; communication and consensus (n=3)41 57 67; roles in care or decision-making (n=3)38 64 67; life-sustaining interventions (n=2)49 70; unspecified decisions (n=2)38 53 and decisions about eating and drinking (n=1).51
The decision-making process
The decision-making process refers to how healthcare professionals make decisions about the identification of whether a patient is dying. Excerpts were categorised as to whether the decision-making process was judged to show evidence for full, partial or no collaboration (table 2).
Five excerpts provided evidence for both information-sharing and joint decision-making and were judged to show full collaboration. However, most excerpts (n=44) showed evidence for either information-sharing or joint decision-making, but not both. These excerpts were categorised as showing partial collaboration. Information-sharing (n=32) was more common than joint decision-making (n=12). This implies that on many occasions although information was shared within the team, decision-making was undertaken by only one member of the MDT. Some excerpts (n=18) included no evidence of either information-sharing or joint decision-making and these were categorised as showing no collaboration. Recurring subthemes in the excerpts were disagreement between team members and how doctors were described as sole decision-makers.
Prognostic decision-making in specialist palliative care settings
Six included studies were conducted in specialist palliative care settings such as hospital specialist palliative care units41 44 48; hospices39 41 46 48 and one community nursing/hospice facility.55 Three studies were conducted in multiple settings, including specialist palliative care.41 48 55 However, relevant excerpts from these studies did not specifically involve staff from specialist palliative care, and therefore, could not be used to describe decision-making characteristics in that setting.
Dee and Endacott39 reported no evidence for collaborative decision-making processes in the included excerpts from their study conducted in a hospice inpatient unit. These excerpts showed how nurses felt their opinions were not considered, and how there were issues with communication between nursing staff and doctors (see D#22–24 in online supplemental file 2).
Similarly, Gambles et al’s46 study conducted in an in-patient hospice also provided no evidence for collaboration. However, the relevant excerpt reported that nurses have more influence, responsibility and could act as decision-makers (see D#29 in online supplemental file 2). The excerpt also showed that this non-collaborative process was viewed positively by doctors. This finding stands in contrast to a recurring theme in other excerpts, in which doctors are described as sole decision-makers.
Pontin and Jordan44 conducted a study in a hospital specialist palliative care setting and presented evidence for partial collaboration. They showed how nurses share information and keep doctors up to date, and how doctors value nurses’ assessments and regard them as better prognosticators because of their level of contact with patients (see D#55 in online supplemental file 2).
Decision-making barriers, opportunities or recommendations
Half of the included studies (n=20) reported barriers, opportunities, or recommendations about MDT decision-making. These included more effective communication, improved collaboration and teamwork, and end-of-life training. Communication and collaboration were often closely linked together.
The most prominent theme across studies was the need for improved communication.41 43 45 48 55–59 61 69 Training in communication skills may ease role anxiety and make professionals more effective.58 One study suggested that communication should address priorities of care especially out of hours, ensuring regular senior review of all dying patients and supporting frontline staff.45 Study authors also proposed better collaboration and communication across services,55 59 71 including structured communication about prognostic information to avoid duplication and fragmentation of services.59 Another study detailed how the healthcare environment itself presents challenges to communication and collaboration and that research is needed on how to better support and structure healthcare environments.69
A need for better collaboration and teamwork was also reported.41 50 57 61 66 69 72 73 The need to respect contributions from all professional groups and avoid discounting the knowledge of staff in subordinate positions was highlighted.50 One study recommended that research should aim to understand the perspectives of team members to enhance understanding of the support and optimal teamwork required to manage end-of-life care.73 Another study proposed that scheduled team rounds might facilitate teamwork in order to better meet complex care needs of dying patients.61 Studies mentioned the importance of reaching team consensus on patients’ palliative care needs in order to make adequate care changes.41 Thus, care and communication processes should be restructured to facilitate team consensus.57
The need for more effective MDTs was also addressed.51 53 58 One study recommended that healthcare professionals from every discipline should be prepared to care for dying patients.51 The need for research and training on improving understanding of end-of-life roles and responsibilities of MDT members was also highlighted.51 58 Chuang et al58 further proposed redesigning workflows, which should include interdisciplinary team rounds. The study by Bostanci et al53 addressed the potential input of allied healthcare professionals into end-of-life discharge planning as well.
Studies also reported the need for educating staff in end-of-life care and about the dying process.43 47 55 56 67 71 72 Studies claimed that appropriate end-of-life care could only be delivered if the culture accepts death and dying as a possible outcome for patients,47 and all team members should be prepared to ‘let go’ at an appropriate time.55 Training should increase awareness of the dying process to ensure that patients have timely access to palliative care and to provide staff with the knowledge and tools to make decisions regarding initiating palliative care.67
Discussion
Using a systematic approach to scoping the available literature, we identified 40 papers from ten countries describing the process of MDT decision-making about the identification of imminently dying patients. Information about the decision-making process was usually available in the form of interview quotes from nurses and doctors. While most decisions focused specifically on professionals recognising that patients were dying, other decisions focused on whether specific end-of-life care pathways should be initiated or dealt with clarifying patients’ care goals. Most excerpts provided evidence for a partial collaborative approach to decision-making, with information-sharing being more common than joint decision-making. Issues with decision-making were articulated through disagreement between staff members. This was closely related to the fact that doctors were often regarded as the final or sole decision-maker.
Limited information was available from specialist palliative care settings. Decision-making in these settings provided evidence for either no or partial collaboration. However, nurses were reported to act as final decision-makers in this setting in contrast to findings from other settings.
Study authors considered that staff collaboration and communication were important and should be improved. Redesigning workflows, including scheduled team rounds, and facilitating consensus within the team might improve MDT working. Authors also expressed the view that end-of-life training should be provided to staff.
Based on these findings, the review identified several areas where further research is required. MDT decision-making on the identification of patients who are dying was not the main focus of any of the included papers. For this reason, the actual decision-making process was not described in any detail. This lack of data on the process of decision-making was a prominent issue in the literature. Future research needs to focus on how MDTs actually make prognostic decisions.
Most of the available data were obtained from interviews. Interviews and qualitative analysis of themes can provide in-depth evidence on the decision-making process. However, studies often only reported one side of the decision-making process, and it was not explained how the same process was perceived by other team members. Audio or video recordings of MDT meetings or discussions would provide data on how decisions are actually made between team members as opposed to interviews that only include team members’ retrospective perceptions of decision-making. Recordings would allow for in-depth analyses of the internal team communication related to these decisions. One study, investigating MDT meetings in an emergency department using conversation analysis, stressed that future research should pay more attention to the details of these meetings, suggesting that researchers should make more use of video recordings whenever feasible.77 Audio and video recordings would allow detailed investigation of the decision-making process during MDT discussions as they occur in situ.
Doctors and nurses were most often part of the decision-making processes reported in included studies. Future research should include allied and other types of healthcare professionals. A number of studies reporting on how allied healthcare professionals were part of decision-making were excluded from this review, because these decisions were often not directly related to identifying dying patients. However, professionals such as chaplains and social workers, although not professionally trained to recognise the same physical and medical signs of deterioration as doctors and nurses, may bring a different perspective to the identification of dying patients. When clinicians are making prognostic decisions, they collate information that can come from their own observations or from others, and as further information is acquired, clinicians review their decisions.78 Allied and other types of healthcare professionals may contribute to the overall picture by sharing observations, supporting other staff members, or providing input that adds important details to overall patient care. As guidelines by the European Association for Palliative Care state: ‘…the complexity of specialist palliative care can only be met by continuous communication and collaboration between the different professions and disciplines in order to provide physical, psychological, social and spiritual support’ (Radbruch and Payne, p. 284).19 Integrating the spectrum of expertise of different individuals into the palliative care plan increases the likelihood that patients are managed in a holistic manner, and it is each professional’s individual expertise that together enables the broad spectrum of patient welfare.79 Future research should therefore aim to explore in more detail what role allied and other types of healthcare professionals can have in the decision-making process. The most important element in prognostication is that team members caring for the patient agree that the patient is dying.80 For this reason, it is important that the whole MDT is included in the decision and that these professionals are included in future research.
The evidence suggests that barriers related to medical authority and power relations might be present. Disagreement between staff members was seen in several excerpts, and in these cases, it was often a doctor who made the final decision and over-ruled other healthcare professionals’ judgements. This might have been due to doctors having medical authority and legal accountability for patient care.81 However, this can be problematic in cases where other staff members have strong opinions about whether or not a patient is dying. Disagreement among team members about prognosis could potentially result in inconsistent patient management and confused communication.80 There might be a causal relation between disagreement and doctors being sole decision-makers. If team members disagree and cannot reach consensus, then the doctor will have to make a decision. However, because the included data only involved staff members’ retrospective accounts, we cannot know for sure how decisions were actually negotiated between members. Usually only one side of the discussion was presented and details of the doctor’s rationale for making a decision were not included. Methods such as judgement analysis82 or the judge-advisor system83 might be able to map how inputs from different team members are weighted. As previously described, video and audio recordings, as opposed to subjective recalls of decision-making, might also be able to shed light on this issue in future studies.
There is a lack of studies on prognostic decision-making in specialist palliative, community and primary care settings. The results from specialist palliative care settings were inconclusive. However, the finding that nurses, rather than doctors, were reported to be final decision-makers in this setting needs further elaboration and investigation. A greater focus on community and primary care settings would be important for future studies since many patients prefer to die at home,84 and facilitating home-deaths is included as a recommendation in the World Health Organization's85 guidelines on palliative care.
Study authors recommended that communication and collaboration should be improved. It was recommended that workflows and communication processes should be restructured to facilitate collaboration and consensus (e.g., through team rounds). A few studies studies have recorded MDT meetings and investigated decision-making using conversation analysis,77 86 discourse analysis or looked at collaborative communication practices.87 88 However, these studies did not focus on how prognostication is carried out within MDTs. Thus, future research should be conducted on how MDTs make such prognostic decisions from an interactional point of view. Such studies would be able to inform evidence-based recommendations on how MDT rounds and discussions could be carried out more effectively.
Strengths and limitations
To our knowledge, this is the first review of MDT prognostic decision-making. The search strategy was broad and inclusive, involving multiple databases to identify any potentially relevant papers. An inclusive approach for screening papers was adopted to ensure that relevant papers were not excluded. Screening and data extraction were done in duplicate to add confidence to the robustness of the methods used for study selection.
There are no agreed search terms for the domains covered by this review. This was reflected in the large number of papers found through database searching, and the fact that citation searches yielded a high number of additional papers. These additional studies often focused exclusively on decision-making between doctors and nurses. The latter might also be due to the broad definition of MDTs used for the purpose of this review. We do acknowledge that there are several ways of referring to a healthcare team consisting of more professionals working together. Terms such as ‘multidisciplinary’, ‘interdisciplinary’, ‘multiprofessional’ and ‘interprofessional’ are commonly used, but there is inconsistency in the way these terms are used within literature.89 90 However, multidisciplinary is most frequently used to describe healthcare teams.89 A literature review found that regardless of the terminology used in papers, they all referred to the structural composition of the team, where teams are composed of members from a range of professional backgrounds and disciplines.89 In order to be inclusive, all studies with two or more professionals with different roles or disciplines were included in the review.
Another limitation of this review was a lack of consensus among study authors about the meaning of imminent death. This term and other related ones such as ‘end-of-life’, ‘terminally ill’ and ‘palliative phase’ do not consistently refer to the same time points in the disease trajectory, and there is no agreement about their definition.91 Studies concerning goals of care for seriously ill or deteriorating patients or whether they should be resuscitated were understood to concern, at least partially, whether or not the patient was imminently dying. If a publication did not clearly define these terms in the title or abstract it was necessary to retrieve the full text for further scrutiny. This resulted in a large number of papers needing to be read through and discussed within the study team to reach consensus about whether or not they met the eligibility criteria.
Several papers were also discussed to reach consensus about whether the reported clinical setting was acute care. In those circumstances where the clinical setting was unclear, an inclusive approach was applied. This meant that papers were included if they reported relevant information on MDT prognostic decision-making despite the clinical setting being described as acute or subacute, as long as this was clearly not identified as ICUs, emergency departments or similar acute care settings.
Papers had to be discussed within the study team when extracting and labelling methods of analysis. Several papers did not clearly report what methods of analysis authors had used. The labels used in the review were based on the descriptions provided in the papers. For this reason and since the review does not include critical appraisal of study methods, it was deemed appropriate to use the label ‘general analysis of themes’ to capture studies which reported having identified and analysed themes. Moreover, consensus about using the label ‘thematic analysis’ for studies reporting or referencing a recognisable analytical framework or approach was reached.
The data available on decision-making about identifying imminently dying patients were limited. The relevant data often only represented a few lines of text within the whole paper. Several excerpts had to be extensively discussed within the study team to reach consensus about whether they specifically concerned identification of imminently dying patients and whether the included professionals constituted an MDT.
Conclusions
Using a systematic scoping of the literature, this review has collated evidence available on MDT prognostic decision-making regarding imminent death. Based on these findings, several gaps in the literature have been identified. There is a preponderance of studies using interviews with staff members, but relatively few directly observing and reporting on the processes occurring in MDT meetings. The findings allowed for the following recommendations to be proposed for future research aiming to investigate this topic: Future studies should consider recording MDT discussions in order to provide deeper insights into MDT decision-making. The role of allied and other types of healthcare professionals in decision-making needs further exploration and more research is needed to understand how MDTs make prognostic decisions in specialist palliative care settings.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was not required since the review only involved secondary analysis of published data.
Acknowledgments
The authors would like to thank Dr Bridget Candy and Clinical Librarian Jacqueline Smith for their thoughtful contributions to the design of the review.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @AndreaBruun, @MCPCRD @LindaOostendorp, @steven_bloch, @n_g_white, @lucymitchinson, @sisk_ali
Contributors Conceptualisation and study design: AB, LO, SB, NW and PS. Search strategy development: AB, LO and NW. Conducting searches: AB. Screening results: AB, LO, A-RS and LM. Data extraction: AB and LO. Data analysis: AB and LO. Guidance and solving disputes: SB, NW and PS. Article draft and revision: AB, LO, SB, NW, PS. Approval of final version for submission: AB, LO, SB, NW, LM, A-RS and PS. Study guarantor: PS
Funding The scoping review was part of a PhD studentship supported by the Marie Curie Chair’s grant (MCCC-FCH-18-U).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.