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A lack of time, the wrong situation, fear of frightening people unnecessarily. Research found these are among the reasons why doctors delay having conversations with patients about their future care.

These conversations, called emergency care and treatment planning, allow people to express their preferences for the care they will receive in future emergencies. Doctors can act on people’s wishes if they become too unwell to express themselves.

The NHS is committed to incorporating these conversations into routine clinical practice. However, many doctors avoid having these conversations. Research explored the reasons why.

Researchers observed and interviewed hospital-based clinicians during their everyday practice, including surgeons, acute and emergency care doctors, and doctors who care for older people.

The doctors agreed that these conversations are important. They stressed, though, that they need to happen at the right time and in the right way. Time constraints in pressured hospital environments, as well as clinicians waiting for the right time to have a conversation, meant that sometimes the conversation did not happen at all.

Policies to promote emergency care and treatment planning conversations need to take into account the possibilities and constraints of busy hospital environments, the researchers say.

What’s the issue?

Emergency care and treatment planning is among medicine’s most difficult conversations.

People are asked to discuss their priorities and consider which treatments they would and would not wish to have in the case of an emergency. For example, if they were to have a heart attack (cardiac arrest), would they want to be resuscitated and treated in intensive care?

Patients’ preferences can guide future treatment if emergency care and treatment planning takes place. Recent initiatives in the UK, USA, and Canada have attempted to make emergency care and treatment planning routine in hospitals. In the UK, the new Recommended Summary Plan for Emergency Care and Treatment initiative (also known as ReSPECT) has been developed by Resuscitation Council UK. It aims to prompt discussions between doctors and patients about options for emergency treatment.

Many doctors delay or avoid these conversations due to time pressures, a lack of training, or uncertainty about who is responsible for the conversations.

To understand the personal, organisational, and cultural reasons for avoiding ReSPECT conversations, researchers interviewed doctors, and observed them in everyday practice.

What’s new?

The study included 34 doctors working on various wards in 5 different hospitals in England. A researcher observed their practice and interviewed most of them (20 consultants, 5 junior and 7 middle-grade doctors).

In this analysis, the researchers focused on instances in which ReSPECT conversations were planned but did not happen. They chose case studies in which deferred or missed conversations were central to the observation and interview.

Across the case studies, a key finding was that doctors appreciated the importance of ReSPECT conversations. They recognised that these conversations required sufficient time, attention, and conversational skills on the part of the doctor. They saw ReSPECT conversations as emotionally and ethically sensitive, and aimed to time them according to the patient’s and/or their family’s readiness and needs.

Busy hospital environments, with constant pressures on staffing and time, meant that doctors prioritised urgent ReSPECT conversations, but deferred or entirely missed other ReSPECT conversations. However, the researchers said these deferred or missed ReSPECT conversations reflected a form of care. In the case studies, conversations were deferred or missed in order to respect the right timing for patient and families, enable doctors to have a longer discussion time with patients, and allow patients enough time to consider their preferences carefully.

Why is this important?

Doctors avoided having ReSPECT conversations intentionally out of care for their patients. They felt that the conversations could cause upset if they weren’t given due time and attention. They agreed that the conversations are important, but need to happen at the right time and in the right way.

Many people could benefit from ReSPECT conversations including people with complex health needs and those nearing the end of life. However, doctors lack the time to have ReSPECT conversations with some of these patients.

Barriers to having ReSPECT conversations differed in different ward areas. Surgeons and elderly medicine specialists described waiting for the right time – such as when family were present – but this could mean that the conversation never happened. Emergency and acute care clinicians were under pressure to triage cases and move patients quickly to other wards.

The researchers say that hospital policies on ReSPECT conversations need to account for different constraints on different wards.

What’s next?

Considering how conversations about emergency care and treatment planning fit within doctors' understandings of care could guide the future implementation of initiatives such as ReSPECT. Policies need to consider what is possible within hospital environments. Doctors’ decisions to delay having conversations can be a part of good practice, as they need to commit sufficient time for an in-depth conversation.

Freeing up staff time to have ReSPECT conversations and increasing the involvement of other specialists in the multidisciplinary team (including senior nurses) in ReSPECT conversations could help. It could improve the number and quality of these conversations. This is difficult to achieve, but the researchers suggested that hospital managers could attempt to allocate more resources for emergency care and treatment planning. 

This study was thorough, but did not observe doctors during night shifts, when ReSPECT conversations may have taken place. Further research at other hospitals and on other wards, would be useful. Future research could investigate ways to improve the timely delivery of emergency care and treatment plans.

This study is part of the larger ReSPECT project, which includes other studies exploring how ReSPECT conversations can affect patients’ attitudes towards their care, and the outcomes of that care.

You may be interested to read

This Alert is based on: Eli K, and others. 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. BMJ Open 2022;12:e046189.

More information about the ReSPECT project is available on the Resuscitation Council UK website.

A study by the same researchers investigating the experiences of clinicians: Eli K, and others. Secondary care consultant clinicians' experiences of conducting emergency care and treatment planning conversations in England: an interview-based analysis. BMJ Open 2020;10:e031633.

Funding: This study is funded by the NIHR Health Services and Delivery Research programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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