Skip to main content Accessibility help

The positioning of palliative care in acute care: A multiperspective qualitative study in the context of metastatic melanoma

  • Jennifer Fox (a1), Carol Windsor (a1), Shirley Connell (a1) and Patsy Yates (a1)



The positioning and meaning of palliative care within the healthcare system lacks clarity which adds a level of complexity to the process of transition to palliative care. This study explores the transition to the palliative care process in the acute care context of metastatic melanoma.


A theoretical framework drawing on interpretive and critical traditions informs this research. The pragmatism of symbolic interactionism and the critical theory of Habermas brought a broad orientation to the research. Integration of the theoretical framework and grounded-theory methods facilitated data generation and analysis of 29 interviews with patients, family carers, and healthcare professionals.


The key analytical findings depict a scope of palliative care that was uncertain for users of the system and for those working within the system. Becoming “palliative” is not a defined event; nor is there unanimity around referral to a palliative care service. As such, ambiguity and tension contribute to the difficulties involved in negotiating the transition to palliative care.

Significance of Results:

Our findings point to uncertainty around the scopes of practice in the transition to palliative care. The challenge in the transition process lies in achieving greater coherency of care within an increasingly specialized healthcare system. The findings may not only inform those within a metastatic melanoma context but may contribute more broadly to palliative practices within the acute care setting.


Corresponding author

Address correspondence and reprint requests to: Jennifer Fox, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, 4059, Queensland, Australia. E-mail:


Hide All
Alvesson, M. & Sköldberg, K. (2009). Reflexive methodology: New vistas for qualitative research. London: Sage Publications.
Arber, A. (2007). “Pain talk” in hospice and palliative care team meetings: An ethnography. International Journal of Nursing Studies, 44, 916926.
Australian Cancer Network Melanoma Guidelines Revision Working Party (2008). Clinical practice guidelines for the management of melanoma in Australia and New Zealand. Sydney: Cancer Council Australia and Australian Cancer Network. Available from
Australian Government (2014). Causes of death, Australia, 2012. Canberra: Australian Bureau of Statistics. Available from
Australian Institute of Health and Welfare (AIHW) (2010). Cancer incidence projections: Australia, 2011 to 2020. Cancer Series no. 66. Cat. No. CAN 62. Canberra: Australian Institute of Health and Welfare. Available from
Australian Institute of Health and Welfare (AIHW) (2012). Australia's health 2012. Australia's Health no 13. Cat no. AUS 156. Canberra: Australian Institute of Health and Welfare. Available from
Bakitas, M., Byock, I.R., Ahles, T.A., et al. (2009). Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: The Project ENABLE II randomized controlled trial. The Journal of the American Medical Association, 302, 741749.
Barry, C.A., Stevenson, F.A., Britten, N., et al. (2001). Giving voice to the lifeworld: More humane, more effective medical care? A qualitative study of doctor–patient communication in general practice. Social Science & Medicine, 53, 487505.
Baszanger, I. (2012). One more chemo or one too many? Defining the limits of treatment and innovation in medical oncology. Social Science & Medicine, 75, 864872.
Blumer, H. (1969). Symbolic interactionism: Perspective and method. Englewood Cliffs, NJ: Prentice-Hall.
Breitbart, W. (2006). The goals of palliative care: Beyond symptom control. Palliative & Supportive Care, 4, 12.
Broom, A., Kirby, E., Good, P., et al. (2012). Specialists' experiences and perspectives on the timing of referral to palliative care: A qualitative study. Journal of Palliative Medicine, 15, 12481253.
Campbell, K.H., Sachs, G.A., Hemmerich, J.A., et al. (2010). Physician referral decisions for older chronic kidney disease patients: A pilot study of geriatricians, internists and nephrologists. Journal of the American Geriatrics Society, 58, 392395.
Casali, P.G. (2011). Medical oncology: The long-awaited prize of recognition. Annals of Oncology, 22(8), 16951697.
Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. London: Sage Publications.
Charmaz, K. (2009). Shifting the grounds: Constructivist grounded theory methods. In Developing grounded theory: The second generation. Morse, J.M. et al. (eds.), pp. 127193. Walnut Creek, CA: Left Coast Press.
Charmaz, K. (2011 a). A constructivist grounded theory analysis of losing and regaining a valued self. In Five ways of doing qualitative analysis: Phenomenological psychology, grounded theory, discourse analysis, narrative research, and intuitive inquiry. Wertz, F.J. et al. (eds.), pp. 165204. New York: Guilford Press.
Charmaz, K. (2011 b). Grounded theory methods in social justice research. In The Sage handbook of qualitative research, 4th ed. Denzin, N.K. & Lincoln, Y.S. (eds.), pp. 359380. Thousand Oaks, CA: Sage Publications.
Clark, D. (2007). From margins to centre: A review of the history of palliative care in cancer. The Lancet. Oncology, 8, 430438.
Ferrell, B. & Grant, M. (2014). The future of palliative care. Seminars in Oncology Nursing, 30, 296297.
Glaser, B.G. (1978). Theoretical sensitivity. San Francisco: University of California Press.
Glaser, B.G. & Strauss, A.L. (1967). The discovery of grounded theory: Strategies for qualitative research. New York: Sociology Press.
Habermas, J. (1984). The theory of communicative action, Volume 1: Reason and the rationalization of society. McCarthy, T. (trans.). Boston: Beacon Press.
Habermas, J. (1987). The theory of communicative action, Volume 2: Lifeworld and system: A critique of functionalist reason. McCarthy, T. (trans.). Boston: Beacon Press.
Hannon, B. & Zimmermann, C. (2013). Early palliative care: Moving from “why” to “how.” Oncology, 27(1), 36. Available from
Hardy, J., Maresco-Pennisi, D., Gilshenan, K., et al. (2008). Barriers to the best care of the dying in Queensland, Australia. Journal of Palliative Medicine, 11, 13251329.
Hibbert, D., Hanratty, B., May, C., et al. (2003). Negotiating palliative care expertise in the medical world. Social Science & Medicine, 57, 277288.
Higginson, I.J. & Evans, C.J. (2010). What is the evidence that palliative care teams improve outcomes for cancer patients and their families? Cancer Journal, 16, 423435.
Hodi, F.S., O'Day, S.J., McDermott, D.F., et al. (2010). Improved survival with ipilimumab in patients with metastatic melanoma. The New England Journal of Medicine, 363, 711723.
Holleb, A.I. (1972). The cancer patient—Too often alone. CA: A Cancer Journal for Clinicians, 22, 129.
Horowitz, R., Gramling, R. & Quill, T.E. (2014). Palliative care education in U.S. medical schools. Medical Education, 48, 5966.
Howie, L. & Peppercorn, J.M. (2013). Early palliative care in cancer treatment: Rationale, evidence and clinical implications. Therapeutic Advances in Medical Oncology, 5(6), 318323.
Hui, D., Elsayem, A., de la Cruz, M., et al. (2010). Availability and integration of palliative care at U.S. cancer centers. The Journal of the American Medical Association, 303, 10541061.
Johnson, C.E., Girgis, A., Paul, C.L., et al. (2008). Cancer specialists' palliative care referral practices and perceptions: Results of a national survey. Palliative Medicine, 22, 5157.
Johnson, C., Girgis, A., Paul, C., et al. (2011 a). Australian palliative care providers' perceptions and experiences of the barriers and facilitators to palliative care provision. Supportive Care in Cancer, 19, 343351.
Johnson, C., Paul, C., Girgis, A., et al. (2011 b). Australian general practitioners' and oncology specialists' perceptions of barriers and facilitators of access to specialist palliative care services. Journal of Palliative Medicine, 14, 429435.
Karnofsky, D. (1960). Why prolong the life of a patient with advanced cancer? CA: A Cancer Journal for Clinicians, 10, 911.
Karnofsky, D. (1962). Rationale for aggressive or extraordinary means of treatment of advanced cancer. CA: A Cancer Journal for Clinicians, 12, 166170.
Krakoff, I.H. (1979). The case for active treatment in patients with advanced cancer: Not everyone needs a hospice. CA: A Cancer Journal for Clinicians, 29, 108111.
Mead, G.H. (1934). Mind, self and society: From the standpoint of a social behaviourist. Chicago: Chicago University Press.
Medical Oncological Group of Australia (2013). History of MOGA. Available from
Meghani, S. (2004). A concept analysis of palliative care in the United States. Journal of Advanced Nursing, 46, 152161.
Oxford Dictionaries (2013). Available from
Parish, K., Glaetzer, K., Grbich, C., et al. (2006). Dying for attention: Palliative care in the acute setting. The Australian Journal of Advanced Nursing, 24(2), 21.
Pincombe, J., Brown, M. & McCutcheon, H. (2003). No time for dying: A study of the care of dying patients in two acute care Australian hospitals. Journal of Palliative Care, 19, 7786.
Potter, J.F. (1980). A challenge for the hospice movement. The New England Journal of Medicine, 302, 5355.
Ramchandran, K. & von Roenn, J.H. (2013). Palliative care always. Oncology, 27, 1316.
Rynearson, E.H. (1959). You are standing at the bedside of a patient dying of untreatable cancer. CA: A Cancer Journal for Clinicians, 9, 8587.
Temel, J. S., Greer, J.A., Muzikansky, A., et al. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer. The New England Journal of Medicine, 363, 733742.
Thompson, J.F., Scolyer, R.A. & Kefford, R.F. (2009). Cutaneous melanoma in the era of molecular profiling. Lancet, 374, 362365.
Tieman, J.J., Sladek, R.M. & Currrow, D.C. (2009). Multiple sources: Mapping the literature of palliative care. Palliative Medicine, 23, 425431.
Wentlandt, K., Krzyzanowska, M.K., Swami, N., et al. (2012). Referral practices of oncologists to specialized palliative care. Journal of Clinical Oncology, 30, 43804386.
White, C.D. & Hardy, J.R. (2010). What do palliative care patients and their relatives think about research in palliative care? A systematic review. Supportive Care in Cancer, 18, 905911.
Willard, C. & Luker, K. (2006). Challenges to end-of-life care in the acute hospital setting. Palliative Medicine, 20, 611615.
Wright, A.A., Zhang, B., Ray, A., et al. (2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. The Journal of the American Medical Association, 300, 16651673.
Yabroff, K.R., Mandelblatt, J.S. & Ingham, J. (2004). The quality of medical care at the end-of-life in the U.S.A.: Existing barriers and examples of process and outcome measures. Palliative Medicine, 18, 202216.
Zimmermann, C., Swami, N., Krzyzanowska, M., et al. (2014). Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet, 383, 17211730.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed