Shared decision-making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting - Observed (STREAMS-O): an ethnographic study
File(s)
Supplementary information
Published version
Author(s)
Warner, Bronwen
Wells, Mary
Vindrola-Padros, Cecilia
Brett, Stephen
Type
Journal Article
Abstract
Background
Shared decision-making is increasingly expected in healthcare. Treatment escalation planning is a contingency for medical intervention in the event of acute deterioration in hospital. Treatment escalation planning guidelines in the United Kingdom reference shared decision-making but it is not clear to what extent this is feasible.
Aim
To understand how shared decision-making takes place during conversations about treatment escalation planning between clinicians and patients in the acute medical setting for older patients with mental capacity to participate in decisions about treatment escalation plans.
Methods
This was a focussed ethnography following a constructivist approach, conducted by a single researcher who is a medical doctor and qualitative researcher with input from a wider research team. Fieldwork took place April-July 2024 in an urban teaching hospital emergency department and acute medical unit. Data was collected as fieldnotes via participant observation, ad-hoc unstructured interviews, documentary analysis and case study analysis. Reflexive thematic analysis was conducted according to Braun and Clarke.
Results
There were five themes, which, collectively, illustrated and explained challenges for shared decision-making with older patients in treatment escalation planning in the acute medical setting: ‘A cog in the hospital machine’, ‘One of many good decisions’, ‘A reluctant conversation’, ‘Gatekeeping the decision’, and ‘Unconstructive conversations’.
Conclusion
Medical rather than shared decision-making was an inevitability in this context due to a complex set of interlinking factors, whilst patients assumed autonomy over their treatment escalation plan. This study questions the prevailing discourse that shared decision-making is always an optimal and achievable approach. Strategies to enhance shared decision-making in treatment escalation plans might include public education and encouraging clinicians and healthcare organisations to review treatment escalation plan decision-making practice. However, deliberation is required at policy level to determine expectations for different stakeholders’ authority over treatment escalation plans.
Shared decision-making is increasingly expected in healthcare. Treatment escalation planning is a contingency for medical intervention in the event of acute deterioration in hospital. Treatment escalation planning guidelines in the United Kingdom reference shared decision-making but it is not clear to what extent this is feasible.
Aim
To understand how shared decision-making takes place during conversations about treatment escalation planning between clinicians and patients in the acute medical setting for older patients with mental capacity to participate in decisions about treatment escalation plans.
Methods
This was a focussed ethnography following a constructivist approach, conducted by a single researcher who is a medical doctor and qualitative researcher with input from a wider research team. Fieldwork took place April-July 2024 in an urban teaching hospital emergency department and acute medical unit. Data was collected as fieldnotes via participant observation, ad-hoc unstructured interviews, documentary analysis and case study analysis. Reflexive thematic analysis was conducted according to Braun and Clarke.
Results
There were five themes, which, collectively, illustrated and explained challenges for shared decision-making with older patients in treatment escalation planning in the acute medical setting: ‘A cog in the hospital machine’, ‘One of many good decisions’, ‘A reluctant conversation’, ‘Gatekeeping the decision’, and ‘Unconstructive conversations’.
Conclusion
Medical rather than shared decision-making was an inevitability in this context due to a complex set of interlinking factors, whilst patients assumed autonomy over their treatment escalation plan. This study questions the prevailing discourse that shared decision-making is always an optimal and achievable approach. Strategies to enhance shared decision-making in treatment escalation plans might include public education and encouraging clinicians and healthcare organisations to review treatment escalation plan decision-making practice. However, deliberation is required at policy level to determine expectations for different stakeholders’ authority over treatment escalation plans.
Date Issued
2025-12-29
Date Acceptance
2025-12-08
Citation
BMC Geriatrics, 2025, 25 (1)
ISSN
1471-2318
Publisher
BMC
Journal / Book Title
BMC Geriatrics
Volume
25
Issue
1
Copyright Statement
© The Author(s) 2025. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
License URL
Identifier
10.1186/s12877-025-06893-7
Subjects
Shared decision-making
Treatment Escalation Planning
Cardiopulmonary resuscitation
Qualitative research
Ethnography
Focussed ethnography
Older people
Publication Status
Published
Article Number
ARTN 1046
Date Publish Online
2025-12-22