Palliative
Medicine
http://pmj.sagepub.com/
'Heated political dynamics exist?…': examining the politics of palliative care in rural British Columbia,
Canada
Valorie A Crooks, Heather Castleden, Neil Hanlon and Nadine Schuurman
Palliat Med 2011 25: 26 originally published online 9 August 2010
DOI: 10.1177/0269216310378784
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http://pmj.sagepub.com/content/25/1/26
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Original Article
‘Heated political dynamics exist . . .’:
examining the politics of palliative care
in rural British Columbia, Canada
Palliative Medicine
25(1) 26–35
! The Author(s) 2011
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269216310378784
pmj.sagepub.com
Valorie A Crooks Department of Geography, Simon Fraser University, Canada
Heather Castleden School for Resource and Environmental Studies, Dalhousie University, Canada
Neil Hanlon Geography Program, University of Northern British Columbia, Canada
Nadine Schuurman Department of Geography, Simon Fraser University, Canada
Abstract
Palliative care is delivered by a number of professional groups and informal providers across a range of settings. This
arrangement works well in that it maximizes avenues for providing care, but may also bring about complicated ‘politics’
due to struggles over control and decision-making power. Thirty-one interviews conducted with formal and informal
palliative care providers in a rural region of British Columbia, Canada, are drawn upon as a case study. Three types of
politics impacting on palliative care provision are identified: inter-community, inter-site, and inter-professional. Three
themes crosscut these politics: ownership, entitlement, and administration. The politics revealed by the interviews, and
heretofore underexplored in the palliative literature, have implications for the delivery of palliative care. For example, the
outcomes of the politics simultaneously facilitate (e.g. by promoting advocacy for local services) and serve as a barrier to
(e.g. by privileging certain communities/care sites/provider) palliative care provision.
Keywords
Administration, Canada, entitlement, ownership, palliative care, politics, professional, qualitative, rural
Introduction
In developed nations, palliative care is typically delivered by a number of professional groups and informal
providers across a range of settings.1,2 These settings
include hospitals, community-based long-term care residences, and private homes.3 Having diversity in both
care providers and sites of care is a strength of palliative
care, as it enables provision to be responsive to a range
of patient needs.4 This diversity can also pose challenges. One challenge comes from the need to seamlessly fit together the markedly different training and
professional backgrounds that palliative care providers
have.1,5 A second challenge comes from the fact that
palliative care services do not operate in isolation but,
as with other health services, are subject to larger decision-making processes (e.g. funding allocation,
healthcare restructuring).6–9 Challenges such as these
can have significant outcomes for providers’ abilities
to deliver the best possible care to dying individuals
and their families. As we demonstrate in this article,
these challenges can result in the development of a ‘politics of palliative care.’ By this we are referring to the
roles that decision-making power and control play in
determining whether and how palliative care will be
provided by specific people in particular places. The
politics of palliative care can interfere with the compassionate delivery of palliative medicine and care, the
enactment of best practice, and the facilitation of
‘good death’, and thus warrant attention.
The international health services literature has
touched on a range of political-type issues and how
they impact healthcare delivery. Significant attention
has been given to the roles that politically influenced
Corresponding author:
Valorie A Crooks, Department of Geography, Simon Fraser University, 8888 University Dr., Burnaby, British Columbia V5A 1S6, Canada
Email: crooks@sfu.ca
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Crooks et al.
27
or politically motivated decision making, particularly
regarding service allocation, play in promoting tensions within and between various stakeholders. In the
Canadian context, this research attention spans issues
as diverse as the closure of health service sites,10
involvement of the public in health service decision
making,11 impact of a shift to regionalized administration on health service delivery,12–14 and impact of
health policy change on health service use,15 among
other topics. This literature collectively demonstrates
the roles that factors, such as power, influence, and
geographic location, play in determining where
health services are and are not delivered in Canada.
Certainly, this is not a reality that is limited to the
Canadian context. For example, a recent comparative
study clearly demonstrated the highly impactful role
of local and national politics in shaping the provision
of community care in Britain and Finland.16 Health
service studies that focus on issues such as these
have placed their focus on community-level politics.
However, the politics of health service delivery have
been found to not rest solely at the community level.
Issues such as aggression and conflict between professional groups,17,18 changes that increase the responsibilities of some provider groups and decrease those of
others,19,20 and general demonstrations of ‘professioncentrism’21 can all bring about political displays of
power and control between healthcare providers.
While the broad health services literature has
focused on exploring community-level politics and the
roles they play in shaping resource allocation and service delivery, little attention has been paid to those that
ultimately shape palliative care delivery specifically.
A notable exception is the scant literature focused on
the role of communities, and community capacity, in
enhancing local palliative care provision (e.g. Kelley22
and Payne et al.23). Meanwhile, dedicated attention has
been given to the inter-professional politics that arise
from providing palliative care to patients and their families. Teamwork and collaborative practice are considered central to the very philosophy of palliative care
provision.1,24 Yet, it has been observed that palliative
care teams can be rife with politics. Interactions
between professionals who are not part of a formal
team but are connected by their shared responsibility
for patient care can also have political undercurrents.25
At the most basic level, Bliss et al.1 contend that confusion over the very responsibilities that different professionals have in providing palliative care can create
tension. Having care providers spread across numerous
sites (e.g. the hospital, in-home care, community practice) can negatively affect the development of effective
communication between individuals, which can cause
or exacerbate struggles.8,26 Inter-professional and
inter-personal politics in palliative care can yield a
range of negative outcomes. For example, Walshe
et al.25 have found that providers may avoid interacting with those whom they have negative relationships or little confidence in. This behavior has the
potential to significantly disrupt patient care because,
as Cartwright26 has observed, relationships between
care providers affect the ‘adequacy, effectiveness, and
humanitarianism’ of palliative care (p. 350).
The objectives of this article are to: (1) articulate
the different levels of politics at play in palliative
care service delivery in a rural region of the Canadian
province of British Columbia; (2) identify themes that
crosscut the politics at play in each level; and (3) consider the implications of these politics for palliative
care practice and delivery. We achieve these objectives
by drawing on the findings of a qualitative case study
undertaken in the rural interior region of British
Columbia known as West Kootenay-Boundary
(WKB). This analysis helps to provide a comprehensive
understanding of the politics of palliative care by
moving beyond the more limited and traditional focus
on inter-professional politics exclusively to include
inter-site and inter-community politics. The analysis is
also intended to make a useful contribution to the rural
palliative care literature. There have been increasing
calls to devote research and practice attention to rural
palliative care, particularly in light of concerns that
rural communities are not well served by simply adopting or adapting more standard urban models of practice.27–29 Interestingly, rural places are also known for
particular kinds of local politics due to their frequently
reported tight-knittedness and strong sense of community spirit that promote involvement in local issues.30,31
Focus groups conducted with rural Canadians also
found that rural residents believe they have unique perspectives on dying and the provision of palliative care.32
Thus, the rural context of this case study is central to
our exploration of the politics of palliative care.
Methods
The case study methodology is employed when
researchers want to achieve an in-depth understanding of a particular issue and its relevant context.33
In this study we – a team of four health geographers
with expertise in spatial and qualitative methods –
employed an instrumental case study design34 to
explore how barriers and facilitators to rural palliative
care delivery play out in practice, and the implications they may hold for enhancing service delivery.
The overall study aim was to explore the potential for
enhancing rural palliative care delivery in British
Columbia using a hub approach.35 In summer 2008
interviews (n ¼ 31) were conducted with formal (i.e.
paid providers who typically have formal training)
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28
Palliative Medicine 25(1)
and informal (i.e. unpaid providers, such as volunteers
and family caregivers) palliative care providers in three
communities that comprise the geographically bounded
case study. In case studies, initial analyses are typically
conducted in order to thoughtfully select the area of
focus.36,37 Consistent with this approach, the WKB
was selected for qualitative data collection as it was
determined to be an underserviced rural area with
regard to palliative care through a series of spatial analyses conducted earlier using health service and population data.38 After further spatial analysis, the region
was also found to be highly suitable for enhancing its
palliative care services.39 This made it an ideal location
in which to explore barriers and facilitators to rural
palliative care enhancement.
Case study context
Context is integral to designing and interpreting the
results of case studies,40 and the present study is no
exception. The geographic distribution of and relationships between communities in the WKB region are
important contextual elements. The WKB is located
in the province’s interior and has a number of small
towns and cities that are widely dispersed across the
region’s mountainous terrain (see Figure 1). Guided
by the findings of our spatial analyses, three specific
communities were selected as the focus of this case
study: Castlegar, Nelson, and Trail. These communities
have strong and distinguishing identities, due in part to
historical patterns of migration and economic investment, which are recognized throughout the region.
Trail is a ‘working-class’ resource center with the largest population of the three communities. Castlegar is
the smallest, and is centrally located in the WKB.
Nelson is known for attracting more ‘alternativeminded’ residents and activities (e.g. craft industries,
artists). In addition to differences in local culture,
there are also long-standing animosities between
the three communities concerning ‘who gets what’
(e.g. the airport in Castlegar, the regional hospital in
Trail) that are an important aspect of the spatial organization (and politics) of health services in the WKB.
Like most Canadian provinces, British Columbia
has decentralized many responsibilities for healthcare
governance to regional health authorities. However,
the provincial government retains primary responsibility for overall funding allocations and regulation of
regional health authority performance.41 Thus, the provision of palliative care is highly varied throughout
the province. Rural palliative care has not been the
focus of systematic planning and development either
before or after decentralization.38,42 This is evidenced
in the WKB by a dearth of palliative-focused services
in many of the communities served by the regional
health authority. For instance, there is no freestanding hospice, and fewer than ten beds have been designated for palliative care across the three communities.
The WKB presents several challenges to health service
organization and delivery, including for palliative care,
Figure 1. The mountainous case study region.
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Crooks et al.
29
that compound the issues brought on by decentralization due to its small rural settlements dispersed over
mountainous topography. For example, the region’s
mountainous terrain limits timely movement between
palliative care sites, particularly in the winter months.43
Recruitment
After obtaining ethical approval for the study from
Simon Fraser University and the Interior Health
Authority, a purposeful recruitment strategy was
employed to identify potential phone interview participants from the three communities. This strategy was
selected in order to maximize diversity in respondents’
locations of practice/residence and occupations.
Potential participants were first contacted using our
existing networks. Next, calls for participants were
placed on listservs run by relevant organizations operating in the WKB. Calls for participants were also circulated through snowball sampling from existing
participants (i.e. asking participants to suggest others
who might be willing to speak with us), by reviewing
employee listings for local health service sites, and
through targeted internet searches.
In total 40 people were invited to participate
in a phone interview, 31 of whom ultimately took
part. Their occupations are summarized in Table 1.
Participants identified their main community of practice/residence to be: Trail (n ¼ 11), Nelson (n ¼ 5), and
Castlegar (n ¼ 13). Many of the formal providers interviewed practiced across the three communities despite
being based out of one. Two participants were based in
rural northern British Columbia. Both of these participants had great familiarity with the state of rural palliative care across the province, and directly asked to
participate in the study. After careful consideration it
was determined that their input could provide an
important comparative perspective, and useful context
at the very least, and so they were interviewed. Their
responses were found to complement those of the WKB
Table 1. Participants’ roles in palliative care service provision
Role/occupational group
Number
Nursing
Healthcare administrator
Hospice/palliative care volunteer
Other
Family doctor
Pastor/minister
Hospice society worker
Allied healthcare professional
Family caregiver
7
6
5
4
2
2
2
2
1
respondents and were integrated into the dataset, rather
than kept distinct for comparative purposes.
Data collection
Formal and informal palliative care providers interested
in participating in an interview were sent detailed information about the study along with a consent form that
they completed and returned prior to the phone interview. Interviews lasted on average 1.5–2 hours. All interviews were conducted by a single interviewer, the second
author, in order to enhance consistency. Interviews were
conducted by phone as the interviewer was not based in
the case study region; face-to-face interviewing was not
possible due to financial constraints. Although nuances,
such as facial expressions, may have been missed because
interviews were not conducted in-person, the cost effectiveness of phone interviewing was ultimately what made
the study feasible. Feasibility is, in part, why phone
interviewing is becoming a common method of qualitative data collection, but also because it is known to yield
high-quality data.44 During the interviews participants
were asked open-ended questions about: their experience
with providing palliative care; community descriptions;
community healthcare and health challenges and priorities; community need for palliative care and existing
availability; and enhancing service delivery. They were
also asked a series of 21 Likert-scale questions at the end
of the interview that probed in more detail the service
hub approach.
Analysis
Interviews were digitally recorded and transcribed verbatim. The data were managed using the N8TM software program. The first step in the analysis was for
each of us to conduct independent transcript reviews.
We next held a team meeting in order to identify issues
emergent from the dataset that warranted analysis.
Five meta-themes were identified: (1) the role of place
in rural palliative care provision; (2) Aboriginalfocused palliative care; (3) health service administration; (4) visioning for secondary rural palliative care
service hubs; and (5) the politics of palliative care.
The focus of this article is exclusively on this last
theme. A thematic approach to the analysis was then
undertaken.45 To do this a coding scheme was collaboratively developed to organize the dataset. The second
author then undertook the coding. Coding extracts relevant to the meta-theme were next shared between the
first and second authors, who created an interpretive
matrix to guide the thematic analysis of the findings.46
One axis characterized the levels of politics identified in
the dataset, while the other contained three crosscutting
themes. The cells of the 3 3 matrix were then
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30
Palliative Medicine 25(1)
populated with findings unique to each. Confirmation
was sought from all investigators concerning the interpretation of the findings. This collaborative approach
to data coding and interpretation in the analytic process strengthens the credibility and integrity of the
results and enhances overall rigor.47
In terms of the presentation of the analytic findings in
the remainder of the article, while all participants offered
insights into the politics of palliative care, we have carefully selected quotation extracts that best illustrate particular political dimensions. This procedure is in keeping
with standard qualitative data interpretation.48 We do
not give any identifying information for quotes as the
WKB region is small, and the provision of palliative care
in the region is even smaller, and so the risk of identifying participants is high should descriptors such as occupation or location be used. Finally, the quote extracts
are substantial in size as they are intended to give readers
the opportunity to ‘hear’ participants’ voices, thereby
maintaining the richness of the data.48
Results
Thematic analysis of the interviews revealed three
levels of politics taking place regarding palliative care
in the WKB: inter-community, inter-care site, and
inter-professional. Three themes were found to crosscut
these levels. Firstly, the issue of ownership was frequently raised by participants. The notion of patient
ownership is often discussed in the health services literature (e.g. Drazen;49 Andrews50), wherein it describes
‘the philosophy that one knows everything about
one’s patients and does everything for them . . . and
[it] is fundamental when facing critical patient care
decisions’ (Van Eaton:51 p.230). As is shown in this
section, the notion of ownership also extends to other
levels, wherein, for example, palliative care service sites
demarcate ownership over existing resources. Secondly,
participants expressed a sense of entitlement to palliative care resources, and particularly towards the allocation of new resources, across all three levels of politics.
A number of different rationales, which are discussed
below, were shared in order to justify notions of entitlement. Finally, healthcare administration was widely
discussed as a key component of the politics of palliative care. Specifically, the regional health authority’s
decision-making processes were perceived to be politically motivated when it came to decisions that left one
community, site, or group with more or less resources
than the others. While there is clear overlap between
the levels of politics identified and the themes that
crosscut them, we tease them apart in the presentation of the findings below in order to illuminate the
true scope of politics of palliative care operating in
the WKB.
Inter-community politics
Ownership. Recent healthcare reform in British
Columbia has led regional health authorities to close
many care sites, thus impacting the availability of
healthcare, including palliative care. Communities in
the WKB have experienced a palpable sense of loss of
ownership as services were taken away: ‘ . . . it’s very
hard because for me, and quite a few of us in town, we
were devastated when we lost our hospital, and you’re left
with a really bitter [taste].’ In the WKB, this reform
has left some communities frustrated with the regional
health authority for designating Trail as the host community for the regional hospital. As a participant
explained: ‘That’s been the argument in [the WKB] all
the time. You know, well, Trail isn’t in the geographic
centre, and Castlegar is. We should have the regional
hospital there.’ Participants expressed concern regarding political and economic biases in the regional health
authority’s decision-making processes. These biases
were thought to hold important implications for determining which communities will ultimately hold ownership for various palliative care services, including the
local benefits this bestows upon them (e.g. high potential spatial access). Another concern is the seeming lack
of a geographic rationale for locating services in Trail,
particularly as some of the WKB’s designated palliative
care beds are hosted by the regional hospital, thus
determining where people can access such care.
Entitlement. Participants explained that local administrators commonly make and justify arguments for
where new palliative care services or resources should
be located, based either on the notion that a lack of
existing resources in a community warrants entitlement
to future ones, or that the presence of existing resources
in a community warrants entitlement for future ones. In
the case of the WKB, the former rationale serves to
justify why Castlegar and Nelson are entitled to new
localized palliative care resources to compensate for
existing service gaps, while the latter rationale serves
to justify ‘stockpiling’ all available and future resources
in Trail to enhance its existing services. Clearly, these
rationales are highly contradictory. It was also noted
that some healthcare administrators and palliative care
providers are quite resigned to thinking they will not
receive further resources despite feelings of entitlement
to them. For example, a participant explained that if
‘the [regional health authority] was to say that [a new
service was] going to be in Trail - which is the most likely
place that they would put it . . . because that’s where the
regional hospital [is] . . . - Nelson would just go ‘‘Oh, oh
well. That’s the way it is, that’s the way it’s always
been’’.’ Regardless of the rationale for why a community perceives itself to be entitled to more resources,
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Crooks et al.
31
there was acknowledgement that a sense of entitlement
may not translate into acquiring additional local palliative care resources.
Administration. Offering a full suite of palliative care
services in all rural communities is not fiscally possible;
participants appreciated that the regional health authority had to make difficult allocation decisions because of
this reality. A participant commented: ‘I know some of
our community administrators would say they’d prefer to
see a budget divvied up [by service] and just let us [palliative care providers] do our thing . . . and that doesn’t
always work.’ Comments such as this show awareness
for the types of challenges faced by administrators.
However, there is also an awareness that past administrative decisions are now contributing to present intercommunity politics, including tensions regarding which
community hosts palliative care services and sites. It was
observed by a number of participants that: ‘There is so
much animosity between Nelson and Trail particularly,
that again, it [decision-making] becomes extremely dysfunctional . . . and so, people make decisions . . . that aren’t
made for reasonable reasons, it becomes extremely emotional.’ These tensions are exacerbated when top-down
decisions are made that leave resource-poor communities criticizing the regional health authority for not
meaningfully consulting with local providers and administrators. When reflecting on this reality, a participant
explained that the regional health authority ‘sometimes
tends to impose things on [communities], and that’s not
always well accepted. I think we would do much better if
we could work from the grass roots up . . . It’s not going to
be perfect for anybody, but everybody has some investment
in it.’ Although community-based administration may
allow for locally responsive service delivery, there was
broader recognition that administration is challenging
and may require resources that are beyond the capacity
of individual communities.
Inter-site politics
Ownership. Paralleling the community-level politics,
conflict between care sites across and within communities is also taking place in the WKB. The need for
patients to receive care in a particular site creates tensions between care sites because ‘owning’ a patient also
means receiving the subsequent funding for that person’s
care. Care sites all want access to financial resources and
so any sense that patients are being referred to sites due
to partiality, nepotism, or any other reason is controversial. For example, it was noted that physicians may favor
one care site over another for referral, which can cause
tensions between facilities. The fall-out of this can negatively impact palliative care recipients and their families. Politics and power struggles also play out between
care sites in instances where professional committees
convene to determine palliative bed allocation. For
example, it was explained that: ‘There is a committee
that meets and provides services, particularly to the [palliative care] beds that are in [privately funded long-term
care facility], that decides who can go there. So there’s a
couple of physicians that have a special interest. There’s a
lot of politics that goes on.’ It is interesting to note that
in this extract the participant explicitly refers to this
situation as causing, or exacerbating, the politics of
palliative care.
Entitlement. Participants explained that care sites in
the WKB are pitted against one another when forced
to make claims of entitlement to palliative care funding
and resources. This particularly happens when allocating
funds between private home-based care and institutional
settings. It was further explained that while the home is
(theoretically) prioritized as a site of palliative care,
reforms have left home care workers limited in the number of hours of service they can provide and the range of
tasks they are permitted to do. This is making it less
realistic for families to use the home as a care site and
more likely for them to rely on the hospital. Many participants were frustrated by this: ‘If people want to palliate at home, we should do everything we can to keep them
there. Unfortunately it’s very difficult in [the WKB] to
keep people at home because we don’t have enough services
to keep them at home. So it’s kind of like mixed messages,
we want to keep them at home, that’s [the regional health
authority] goal, but we just don’t have enough resources
to actually do that.’ Given this, many participants
argued that home care services, particularly those that
enable the home to be a site of care, were entitled
to receive renewed palliative care funding and training
opportunities.
Administration. At present, funding for palliative care
is divided between care sites (e.g. home care versus institutional care) and there is a lack of political will to create
a shared budget across them. This frustrated some participants, as it was acknowledged that creating a shared
budget may, in fact, reduce territorialism and notions of
ownership. An outcome could be that providers could
have more focus on care rather than issues of ownership
and entitlement. As a participant explained: ‘There has
to stop being a dividing line between the acute care budget
and the residential care budget and the community care
budget. How ever we fund palliative care, it has to be out
of a shared pot, because palliative care happens in all those
areas and so to say ‘‘This is mine, and this is mine, and this
is mine’’ is what fragments it and then nobody wins, and
nobody has enough resources.’ Institutionalized administrative structures also create politicized tensions. For
example, while the bulk of palliative care patients receive
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32
Palliative Medicine 25(1)
care in the home at some point, hospital rounds are only
for people receiving on-site care. This leaves home-based
and medically intensive patients in long-term care facilities beyond the reach of this expertise. It was also
revealed that a shift in the place from where home care
administration happens (i.e. out of the hospital and into
a community office) has enhanced the perceived divide
between home and institutional care. A participant who
works out of this office explained that s/he was ‘much
more involved in the hospital’ when the office was based
there, and favored its return to there.
Inter-professional politics
Ownership. Rural family physicians typically provide
patient care from birth to death. While there are many
benefits to having this long-standing relationship, it can
also create a sense of patient ownership. It was explained
that this sense of ownership, in turn, may minimize physicians’ help-seeking behaviors as individuals move
from ‘patients needing treatment or cure’ to ‘palliative
patients in need of pain and symptom management’. A
participant reflected on this issue, explaining that ‘in
terms of referrals . . . there [is], a little bit of, sort of territorialism . . . Historically in our area, many of the physicians have . . . just wanted to look after their own clients,
or their own patients.’ It was further observed that personality conflicts between providers can confound decision-making regarding symptom management or when
giving up oversight of a patient. As this participant
explained, such situations become politically charged:
‘We had a nurse . . . [who] had quite a high level of [palliative care] expertise but there was politics there as well,
in that the nurses from home nursing care, who had historically always been the people who were right up on
things for palliative care, didn’t want to refer to [this
person], didn’t want to consult with [this person] . . . I
think the home care nurses were threatened. They didn’t
like somebody coming in and telling them . . . how to do
pain and symptom management.’ In this case, having
one provider with ownership of more specialized palliative care expertise created tension among the team
within which s/he was situated, thereby creating or exacerbating a politics of palliative care.
Entitlement. There was an underlying sense held by
some participants of being entitled to provide palliative
care to patients because of the experience, expertise, and
relationships they have built up over time. This was true
regardless of whether or not they had received formal
training in this area of practice. Contrary to this, it was
observed that in some instances specialized credentials
are used to usurp first-hand experience. In such cases
credentials are used as a form of entitlement to oversee
a patient’s care. Having to work where some providers
have specialized training and others do not, and some
have lengthy hands on experience and others do not, has
resulted in an environment that one participant
described as ‘very political’. The long-standing hierarchy
that exists among medical professions was reported to be
in force in the WKB. As one participant explained, this
hierarchy can negatively impact working relationships,
including access to information between professional
groups: ‘It’s hard to get into the ‘‘doctor world’’ to
really know what’s going on . . . doctors are very territorial . . . and it’s one of those sort of ‘‘group phenomenon’’
things that if you’re different . . . it makes it very difficult . . . ’ It was commonly reported that tensions between
provider groups are exacerbating conflicts over who is
entitled to make which palliative care decisions, and who
holds the ability to overrule others’ decisions.
Administration. Political will has a major impact on the
allocation of funding for palliative care services in the
WKB. At present, service coverage is thought to be insufficient and limited. Those services that are available are
constantly at risk of further cuts from a top-down regional health authority administration. Many providers
perceive the health authority to be making arbitrary decisions based on ‘back-room’ politics. For example, the
cutting of a palliative care nursing position was attributed
to professional and administrative politics. This cut was
seen as a significant loss to communities’ palliative care
provisioning: ‘[The nurse] still has such a passion for palliative care and pain and symptom management, and so
much expertise to give, but the [regional health authority]
is not amenable to having a pain and symptom management
nurse . . . [it was] the politics of [name of regional administrator] . . . not wanting to apply funding there.’ To prevent similar situations from happening again, it was
explained that transparent and frequent communication
between professionals, sites of care, and communities will
be critical to assuaging the politics of palliative care.
Using a common analogy, a participant described this
desired situation as letting ‘the right hand . . . [know]
what the left hand is doing.’
Discussion
Thematic analysis of interviews conducted with formal
and informal palliative care providers has revealed
three levels of politics at play in the WKB region.
Inter-community politics highlight struggles regarding
service allocation and funding, inter-site politics draw
attention to issues of local resourcing and its distribution, while inter-professional politics bring to light
challenges associated with collaborative practice and
professional hierarchies. Three crosscutting themes
were found to characterize how these politics play out
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Crooks et al.
33
with regard to palliative care: ownership, entitlement,
and administration. These themes reveal common factors that promote politics at all levels. Regarding ownership, politics commonly emerged due to observations
of others having access to resources or decision-making
power above and beyond what some do. These observations were then leveraged as a justification for why
additional palliative care resources or decision-making
power was needed for the relatively deprived group,
site, or community. While the uneven distribution of
resources or decision-making power was a factor promoting politics around ownership, historical precedents
were more frequently discussed in relation to entitlement. If a community, site, or group was favored in
the distribution of palliative care resources or decision-making power, over time it was expected that
that this would continue, while others used this same
rationale to justify why they were entitled to benefit
from future allocations. Finally, structural aspects surrounding the organization and practice of services were
frequently cited as administrative factors that, in turn,
reinforced or promoted the politics of palliative care in
the WKB. These findings reveal how complex and
interrelated various levels of politics in palliative care
can be. They also serve to extend the more traditional
focus placed solely on inter-professional politics in the
palliative care literature, as explained in the introductory section.
In this qualitative case study we set out to explore
how barriers and facilitators to palliative care delivery
play out in practice in the WKB, and the implications
they may hold for enhancing service delivery. The politics of palliative care was not initially an issue of focus.
However, upon review of the transcripts it was revealed
that inter-community, inter-site, and inter-professional
politics can act as important barriers and facilitators
to care delivery. For example, they act as a barrier
through creating a trickle-down effect, whereby rifts
and tensions can ultimately negatively impact patients
and their families (e.g. by limiting choice) and providers
(e.g. in having to negotiate fractured professional relationships) alike. At the same time, they can act as a
facilitator by pushing some palliative care providers
and others into playing advocacy roles, thus raising
awareness of palliative care issues and needs in the
WKB. Such findings demonstrate the importance of
understanding and seriously taking into consideration
the ‘political dimensions’ of palliative care in a particular community or region prior to enhancing services.
This is something that researchers and decision makers
alike must address when taking up the recent calls to
develop new models and modes of palliative care for
rural areas (e.g. Robinson et al.;27 Wilson et al.;28
Crooks and Schuurman29). By voicing the politics of
palliative care at play in the WKB during their
interviews, and particularly when not prompted to do
so, the participants were, in effect, conveying this very
message.
The process of enhancing rural palliative care services may provide communities, sites, and professional
groups with the opportunity to resolve political tensions that have arisen over time due to struggles over
access to decision-making power, as well as human,
financial, and material resources. Specific strategies
for doing this identified by the participants include:
making administrative decision-making more transparent; co-locating different professionals or professional
groups in proximal offices; consulting with stakeholders
when making significant system and service changes;
creating clear guidelines for how patient referrals are
to take place; and putting local resources in place that
are needed to meet regional priorities (e.g. having adequate home care support). Several of these same strategies appear elsewhere in the palliative care literature,
thus suggesting that they have relevance beyond the
WKB. For example, as noted in the introduction,
other studies have demonstrated the potential benefits
of having palliative care providers’ offices located close
to one another. Doing so provides opportunities to
enhance communication and inter-professional collaboration.8,26 Existing research also offers strategies not
specifically identified by the participants that may also
assist with mollifying some of the politics of palliative
care taking place in the WKB and elsewhere. Giving
providers clear role definitions,1 developing a shared
culture of palliative care in the region,24 and providing
opportunities for cooperation between formal and
informal palliative care providers9 are all examples of
strategies discussed elsewhere. Interestingly, it has also
been suggested that the concept of ownership can be
used in a positive way to enhance palliative care. This
can happen when providers, sites, and/or communities
can create a sense of collective ownership over their
goals.2 Finally, it has been noted that at the inter-site
and inter-community levels, lessening the complexity of
palliative care arrangements may also serve to remedy
service challenges;8 this, in turn, may lessen tensions
and ultimately political struggles over decisionmaking power.
Implications for palliative care practice
and delivery
Politics are a pervasive feature of healthcare, and
this study suggests that rural palliative care is no exception. Turf, territory, ownership, and competition were
common tropes used to describe conflict between health
professions, organizations, and communities within the
rural and regional context. In the WKB, the establishment of a regional health authority governance
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34
Palliative Medicine 25(1)
framework provides a platform by which the resolution
of various competing interests can be achieved through
greater attention to local input and conditions, but in
no way mollifies the potential for conflict.52–54 Lines of
accountability, funding flows, program development,
and organizational structures must ultimately work
within the confines of finite resources, but with the
goal of maximizing support within a given jurisdiction
for those in need of care, their families, and informal
support networks. At the level of practice, there is likewise a need for recognition of, and respect for, the talents and capacities of others in the field. This may help
to avoid the ‘game-playing’ that can happen between
palliative care professionals who have negative perceptions of others’ work and skills, thus creating tension
and politics.25 Even more critically, however, providers
must ‘buy-in’ to the notion that more will be achieved
by working toward shared goals, and that this almost
inevitably entails compromise and accommodating collective interests at the expense of individual ones. Doing
so may overcome some of the politics reported herein,
along with the aggression17,18 and ‘profession-centrism’
reported in others’ research.21
We expect that the implications for palliative care
practice and delivery shared here, along with the findings
communicated above, are likely to have relevance to
other places that share a similar context to the case
study region. Perhaps most obvious is the case of rural
Australia, where isolation and distance are comparable
to the rural Canadian context. Both countries are facing
an increasing demand for palliative care along with population aging and the movement of retirees from the city
into the countryside that is amplifying the pressing need
to enhance rural services.55–58 Given these parallels, the
levels and types of politics of palliative care at play in
rural regions of both countries are likely to have similarities, and so the strategies identified to remedy the
politics may also be applicable to both jurisdictions.
Funding
This research was funded by a research grant from the
British Columbia Medical Services Foundation and a
team-building grant from the British Columbia Rural
& Remote Health Research Network. HC was funded
by a postdoctoral fellowship from the British Columbia
Network Environments for Aboriginal Research during
the study period and NS was funded by career awards
from the Canadian Institutes of Health Research and
Michael Smith Foundation for Health Research.
Acknowledgements
We would like to express our thanks to the participants for
their contribution to the study.
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