Discussions about Goals of Care in the Emergency Department: a Qualitative Study of Emergency Physicians' Opinions Using the Normalization Process Theory

Abstract

Purpose We explored emergency department (ED) physicians' opinions about the feasibility of leading goals of care discussions (GCD) in their daily practice. Method This qualitative study was based on the Normalization Process Theory (NPT). We conducted semi-structured interviews between April and May 2018 with a convenience sample of ten emergency physicians from one academic ED (Lévis, Canada) and aimed to reach data saturation. Using a mixed deductive and inductive thematic analysis, two authors codified the interviews under the four NPT constructs: coherence, cognitive participation, collective action, and reflexive monitoring. We calculated a kappa statistic to measure inter-rater agreement. Results We interviewed 10 emergency physicians. No new ideas emerged after the ninth interview and the inter-rater agreement was substantial. Fourteen themes were identified as factors influencing the feasibility of implementing GCD: (1) interpersonal communication, (2) efficiency of care, (3) anxiety generated by the discussion, (4) identification of an acute deterioration leading to the GCD, (5) meeting of the clinician, patient, and family, (6) importance of knowing the patient's goals of care before medical handover, (7) lack of training, (8) availability of protocols, (9) heterogeneous prioritization for leading GCD, (10) need to take action before patients consult in the ED, (11) need to develop education programs, (12) need for legislation, (13) need to improve the ED environment and human resources, and (14) selective systematization of GCD for patients. Conclusion Goals of care discussions are possible and essential with selected ED patients. Physicians identified outstanding needs to normalize GCD in their practice: education for both themselves and patients on the concept of GCD, legislative action for the systematization of GCD for patients, and proactive documentation of patients' preferences pre-ED. Patient, clinician and system-level policy-making efforts remain necessary to address these needs and ensure the normalization of GCD in emergency physicians' daily practice as suggested by clinical guidelines.