Caring in the silences: why physicians and surgeons do not discuss emergency care and treatment planning with their patients — an analysis of hospital-based ethnographic case studies in England

Abstract

BackgroundDespite increasing emphasis on integrating emergency care and treatment planning (ECTP) into routine medical practice, clinicians continue to delay or avoid ECTP conversations with patients. However, little is known about the clinical logics underlying barriers to ECTP conversations.ObjectiveThis study aims to develop an ethnographic account of how and why clinicians defer and avoid ECTP conversations, and how they rationalise these decisions as they happen.DesignA multisited ethnographic study.SettingMedical, orthopaedic and surgical wards in hospitals within four acute National Health Service trusts in England.ParticipantsThirty-four doctors were formally observed and 32 formally interviewed. Following an ethnographic case study approach, six cases were selected for in-depth analysis.AnalysisFieldnote data were triangulated with interview data, to develop a ‘thick description’ of each case. Using a conceptual framework of care, the analysis highlighted the clinical logics underlying these cases.ResultsThe deferral or avoidance of ECTP conversations was driven by concerns over caring well, with clinicians attempting to optimise both medical and bedside practice. Conducting an ECTP conversation carefully meant attending to patients’ and relatives’ emotions and committing sufficient time for an in-depth discussion. However, conversation plans were often disrupted by issues related to timing and time constraints, leading doctors to defer these conversations, sometimes indefinitely. Additionally, whereas surgeons and geriatricians deferred conversations because they did not have the time to offer detailed discussions, emergency and acute medicine clinicians deferred conversations because the high-turnover ward environment, combined with patients’ acute conditions, meant triaging conversations to those most in need.ConclusionOvercoming barriers to ECTP conversations is not simply a matter of enhancing training or hospital policies, but of promoting good conversational practices that take into account the affordances of hospital time and space, as well as clinicians’ understandings of caring well.

Why are some ReSPECT conversations left incomplete? A qualitative case study analysis

“…, 12. , 17. This necessity to respond to clinical time, however, prevents doctors from being led by patients’ own timing, which has been identified as key to end-of-life and future planning conversations.…”

“…, 13. , 17. Narrative medicine scholars have theorised the clinical encounter as a mutual performance in which patient and practitioner co-construct a story of illness, healing, and at times, dying.…”

“…This means that not all the ReSPECT conversations that took place at the designated ward areas during our study period could be observed. 17 As this analysis is based on six case studies, the data are unlikely to have captured all factors that underlie incomplete conversations. Furthermore, given the study’s cross-sectional design, we could not follow up on incomplete ReSPECT conversations to ascertain whether they had led to further conversations.…”

“…As described in our earlier publication, 12 KE observed ReSPECT conversations after being informed by clinical staff that a conversation was about to take place on a selected ward. 17 Conversations took place at patients’ bedsides or private meeting rooms, across various times of day – during or after ward rounds, following multi-disciplinary team meetings, and during visiting hours – and were observed with the agreement of patients and/or their relatives, if present. 12 KE conducted semi-structured interviews with the doctors who conducted these conversations, using a topic guide developed by the study team which explored their perceptions of the conversations, reflections on their practice, and experiences of the ReSPECT process.…”

Patient and relative experiences of the ReSPECT process in the community: an interview-based study

“…An observation- and interview-based study of ReSPECT conversations in hospital found that conversations could be exploratory or persuasive, with doctors taking varying stances toward the extent to which patients’ and relatives’ preferences should direct the recommendations [ 3 ]. An ethnographic study found that some ReSPECT conversations in hospital were not performed due to time constraints and the sensitivity of timing these conversations, while another study found that, in hospital settings, mismatches between doctors’ and patients’ priorities and understandings led to incomplete ReSPECT conversations [ 4 , 5 ]. In addition, interview and focus group studies found that both hospital-based and primary care doctors viewed ReSPECT as a process that required good rapport and careful negotiation of patients’ and relatives’ emotions [ 6 , 7 ].…”