Shared decision-making on treatment escalation planning with older patients in the acute medical setting
File(s)
Author(s)
Warner, Bronwen Elizabeth
Type
Thesis
Abstract
Shared Decision-Making (SDM) is considered best practice for healthcare communication in the United Kingdom (UK). Treatment Escalation Planning (TEP) aims to formulate and document a contingency for medical intervention if a patient deteriorates. Patient involvement in TEP decision-making is subject to ongoing debate. There is a paradox in existing legal and professional guidance wherein patient autonomy is increasingly emphasised but clinicians are not required to provide treatments they deem inappropriate.
In this programme of research, I aim to understand perceptions and practice around shared decision-making for treatment escalation planning with older people in the acute medical setting.
A qualitative approach is chosen because this research seeks a deep understanding of a topic which is nuanced and based on social constructs of good decision-making approaches. The Thesis comprises four workstreams: 1) a systematic review and thematic evidence synthesis of data from previous studies; 2) an interview study of clinician perspectives; 3) an interview study of patient perspectives; 4) an ethnographic account of current practice. Primary studies were conducted in an urban setting and are analysed using reflexive thematic analysis. I synthesise findings from across the workstreams to generate an overarching thematic analysis and propose a socio-ecological model to illustrate factors influencing how SDM is realised for TEP in the acute medical setting.
I find that treatment escalation planning for older people in the acute medicine climate studied is often unlikely to deliver a genuinely shared decision between patients and clinicians and I illustrate the factors which drive it inexorably towards being a medical decision. I discuss the tension between this conclusion and societal expectations for patient autonomy, and propose strategies by which SDM in TEP could be enhanced.
In this programme of research, I aim to understand perceptions and practice around shared decision-making for treatment escalation planning with older people in the acute medical setting.
A qualitative approach is chosen because this research seeks a deep understanding of a topic which is nuanced and based on social constructs of good decision-making approaches. The Thesis comprises four workstreams: 1) a systematic review and thematic evidence synthesis of data from previous studies; 2) an interview study of clinician perspectives; 3) an interview study of patient perspectives; 4) an ethnographic account of current practice. Primary studies were conducted in an urban setting and are analysed using reflexive thematic analysis. I synthesise findings from across the workstreams to generate an overarching thematic analysis and propose a socio-ecological model to illustrate factors influencing how SDM is realised for TEP in the acute medical setting.
I find that treatment escalation planning for older people in the acute medicine climate studied is often unlikely to deliver a genuinely shared decision between patients and clinicians and I illustrate the factors which drive it inexorably towards being a medical decision. I discuss the tension between this conclusion and societal expectations for patient autonomy, and propose strategies by which SDM in TEP could be enhanced.
Version
Open Access
Date Issued
2025-05-11
Date Awarded
01/08/2025
License URL
Advisor
Brett, Stephen
Wells, Mary
Vindrola, Cecilia
Sponsor
HCA Healthcare UK (Firm)
Publisher Department
Department of Surgery & Cancer
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)