Synthesis across studies also requires consideration of how contextual

influences and matters of interpretation are PD332991 addressed [34]. In this synthesis, data collection in the different studies was broadly underpinned by current frameworks for palliative care [9], which provided a consistent reference for interpretation. However we also attempted to synthesise alternative stakeholder views on palliative care within a stroke context. ‘Realist’ work requires a strong stakeholder focus to ensure that emerging theory addresses important issues, and produces useful findings [20]. However, little guidance is available to suggest how different perspectives should Inhibitors,research,lifescience,medical be managed within the process. As we aimed to produce a guiding framework for clinicians and service managers to sustain Inhibitors,research,lifescience,medical the integration of palliative care within stroke services, we ‘focused’ our synthesis through the perspectives of staff drawn from three stroke services. Whilst this should maximise the utility of our findings, we may have under-represented some issues which are important to other stakeholders, including patients and family members. Conclusion Inhibitors,research,lifescience,medical This paper addresses an important gap in the literature by investigating

the interface between stroke and palliative care from the perspectives of patients, family members and stroke service staff. Synthesis of three studies highlights a chain of mechanisms which cumulatively explain these may be integrated around the needs and preferences of patients and family members. Mechanisms relate to the legitimacy of palliative care and individual capacity, engaging with family, the timing of intervention, working with complexity and the recognition of dying. A range of Inhibitors,research,lifescience,medical clinical and service factors appear to influence whether these mechanisms operate, and consequently how palliative care needs are attended to. The beliefs of staff about palliative

care, education and training, communication skills, supported by Inhibitors,research,lifescience,medical partnership working with specialist palliative care provide the basis for the integration of palliative and stroke care to occur. Our findings highlight Linifanib (ABT-869) difficulties in identifying the nature and purpose of palliative care in acute stroke services, including whether palliative care focuses on end of life care, or more general supportive interventions that could (or not) be combined with active treatment strategies. Practical difficulties in identifying when patients require palliative interventions should be the focus of further investigation. Competing interests The authors declare that they have no competing interests. Authors’ contributions CB and SP were involved in the study concept, design, analysis, interpretation of the data and drafting the manuscript. Both authors read and approved the final manuscript. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.