Shared decision making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting: a qualitative study of Clinicians’ perspectives (STREAMS-C)
File(s)
Published version
Author(s)
Warner, Bronwen E
Wells, Mary
Vindrola-Padros, Cecilia
Brett, Stephen J
Type
Journal Article
Abstract
Background
Shared decision-making (SDM) is increasingly expected in healthcare systems prioritising patient autonomy. Treatment escalation plans (TEP) outline contingency for medical intervention in the event of patient deterioration. This study aimed to understand clinicians’ perspectives on SDM in TEP for older patients in the acute medical setting.
Methods
This was a qualitative study following a constructivist approach. Semistructured interviews with vignettes were conducted with 26 consultant and registrar doctors working in Emergency Medicine, General Internal Medicine, Intensive Care Medicine and Palliative Care Medicine. Reflexive Thematic Analysis was performed.
Results
There were three themes: ‘An unequal partnership’, ‘Options without equipoise’ and ‘Decisions with shared understanding’. Clinicians’ expertise in synthesising complex, uncertain clinical information was contrasted with perceived patient unfamiliarity with future health planning and medical intervention. There was a strong sense of morality underpinning decision-making and little equipoise about appropriate TEP decisions. Communication around the TEP was important and clinicians sought control over the high-stakes decision, whilst avoiding conflict and achieving shared understanding.
Conclusions
Clinicians take responsibility for securing a ‘good’ TEP decision for older patients in the acute medical setting. They synthesise clinical data with implicit ethical reasoning according to their professional predictions of qualitative and quantitative success following medical intervention. Shared decision-making is seldom considered a priority for this context. Nonetheless, avoidance of conflict, preserving the clinical relationship and shared understanding with the patient and family are important.
Shared decision-making (SDM) is increasingly expected in healthcare systems prioritising patient autonomy. Treatment escalation plans (TEP) outline contingency for medical intervention in the event of patient deterioration. This study aimed to understand clinicians’ perspectives on SDM in TEP for older patients in the acute medical setting.
Methods
This was a qualitative study following a constructivist approach. Semistructured interviews with vignettes were conducted with 26 consultant and registrar doctors working in Emergency Medicine, General Internal Medicine, Intensive Care Medicine and Palliative Care Medicine. Reflexive Thematic Analysis was performed.
Results
There were three themes: ‘An unequal partnership’, ‘Options without equipoise’ and ‘Decisions with shared understanding’. Clinicians’ expertise in synthesising complex, uncertain clinical information was contrasted with perceived patient unfamiliarity with future health planning and medical intervention. There was a strong sense of morality underpinning decision-making and little equipoise about appropriate TEP decisions. Communication around the TEP was important and clinicians sought control over the high-stakes decision, whilst avoiding conflict and achieving shared understanding.
Conclusions
Clinicians take responsibility for securing a ‘good’ TEP decision for older patients in the acute medical setting. They synthesise clinical data with implicit ethical reasoning according to their professional predictions of qualitative and quantitative success following medical intervention. Shared decision-making is seldom considered a priority for this context. Nonetheless, avoidance of conflict, preserving the clinical relationship and shared understanding with the patient and family are important.
Date Issued
2024-09
Date Acceptance
2024-07-16
Citation
Age and Ageing, 2024, 53 (9)
ISSN
0002-0729
Publisher
Oxford University Press
Journal / Book Title
Age and Ageing
Volume
53
Issue
9
Copyright Statement
© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society.
This is an Open Access ar ticle distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution,
and reproduction in any medium, provided the original work is properly cited.
This is an Open Access ar ticle distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution,
and reproduction in any medium, provided the original work is properly cited.
License URL
Identifier
https://academic.oup.com/ageing/article/53/9/afae204/7775381
Publication Status
Published
Article Number
afae204
Date Publish Online
2024-09-25