Overall, in the interview setting, patients did not elaborate on conversations about preferences for EOLC. This reticence contrasted with the lengthier accounts given about diagnosis in which participants included detailed accounts of how this was delivered and their reactions to the news. Not only did patients and their family carers have little to say about PPC, but when asked, there was also little indication of any expressed needs to engage in such discussions,

and this was the case Inhibitors,research,lifescience,medical across the study sites. While some patients expressed expectations that this would be a topic that HCPs would initiate, there was no sense from the data that patients and family carers felt dissatisfied Inhibitors,research,lifescience,medical where this had not been the case. There may be a number of reasons for patient and family carers’ reluctance to engage with this topic. Some did not see the need to have discussions or felt it was something for ‘further down the line’. It may have been that some lacked knowledge and/or awareness of the options and possibilities to discuss plans for future care. Similar findings were identified Inhibitors,research,lifescience,medical in a study of patients’ with pancreatic cancer in relation to discussions about ‘place of death’ [30]. Copp and Field [26] discuss

how denial and acceptance of dying can fluctuate during the period of dying; these Inhibitors,research,lifescience,medical ‘strategies’ can form coping strategies and may also be employed within research interviews to protect oneself or others taking part in the interview. Our findings indicated equal reticence on the part of the HCPs, who were often hesitant to take a

lead for several reasons. These included concerns about causing distress, taking away hope or touching on topics that the patient was not ready to engage with. A key barrier for HCPs initiating conversations Inhibitors,research,lifescience,medical on the subject is a perceived concern about taking away any hope. However, there is some evidence to suggest that engaging Batimastat in ACP discussions can positively enhance rather than diminish patients’ hopes [31,32]. Timing is another key issue identified in our study. The uncertain trajectory of patients’ ill health can present an additional difficulty for HCPs in judging when to introduce discussions about EOLC, particularly for patients with long term conditions [10,13,33,34]. HCPs frequently made screening libraries judgement calls, often guided by intuition, on patients’ – and family carers’ – levels of awareness or denial. Indeed, the ambivalence of HCPs appears to have been influenced in part by their awareness and sensitivity to their patients’ receptivity to engage in discussions about aspects of ACP.