A Critical Realist Informed Evaluation of End-of-Life Care for People with Dementia in Hospitals.

Abstract

Background: End-of-life care for individuals with dementia in hospital settings is often inconsistent and poorly adapted to their complex needs. The rising prevalence of dementia and its status as a leading cause of death in the UK underscore the urgent need to understand and improve end-of-life care practices in acute care. However, current approaches are limited by a lack of explanatory insight into what works, for whom, and under what circumstances. Aim: To develop explanatory programme theories that inform context-sensitive interventions to enhance the quality and sustainability of end-of-life care for people with dementia in hospitals. Methods: This study employed a two-phased qualitative research design underpinned by critical realist evaluation. Critical realist evaluation provided both the conceptual framework and analytical lens to explore how interventions in end-of-life care for people with dementia in hospitals succeed or fail. The evaluation was structured around identifying intervention mechanisms, internal contextual mechanisms, external contextual mechanisms, and agency, and examining how their interaction shaped care outcomes. Data were collected through semi-structured interviews and focus groups with hospital staff and bereaved relatives. The analysis drew on both inductive and deductive thematic coding to surface key mechanisms and contextual factors, enabling the development of explanatory programme theories grounded in the lived realities of hospital-based dementia care. Findings: Four interrelated programme theories were developed. The training and education theory illustrates how contextual enablers and constraints influence staff learning and communication practices, recommending scenario-based and video-assisted training. The advance care planning theory identifies mechanisms related to personalised care, anticipatory decision-making, and communication, shaped by structural factors such as staffing and policy clarity. The multidisciplinary care theory explains how integrated, cross-disciplinary collaboration and role clarity support holistic assessment and care continuity. The person and family-centred approach theory addresses the emotional and psychological dimensions of care, proposing tailored support mechanisms while recognising resource limitations and cultural sensitivities. Conclusion: This study’s primary contribution lies in its application of critical realist evaluation to develop transferable and evidence-informed programme theories. These theories identify how, why, and in what contexts end-of-life care interventions might succeed or fail for people with dementia in hospitals. They offer a foundation for designing multi- component, context-sensitive interventions that address the realities of hospital practice. Further research is needed to translate these theories into tested interventions and implementation strategies.