"I know you didn't want to stay": emergency department conversations about disposition for people living with dementia.

Background and objectives: When people living with dementia present to the emergency department (ED), the disposition decision-to admit them to the hospital or discharge them home-can be difficult for providers. However, little is known about current real-world practices in disposition conversations.

Research design and methods: This ethnographic study used direct observations of ED encounters with people living with dementia, their care partners, and ED providers at a Veteran Affairs facility in the Southeast United States. Follow-up interviews were conducted with patients and care partners. Interview guides and code book were informed by the Ottawa Decision Support Framework. Data were analyzed using the constant comparative method.

Results: Data were collected over 45 days, with 20 ED encounters, 18 follow-up interviews, and baseline surveys obtained. For the 20 Veteran participants living with dementia, all were male, mean age was 79.4, and 50% were Black or African American. Major themes included: (1) Disposition conversations had significant variation in depth and content, (2) patient and care partner participation varied with disposition, and (3) satisfaction was driven by alignment of disposition preferences.

Discussion and implications: Our study suggests that there are no consistent formats of disposition conversations for people living with dementia. Improving quality may be most needed when preferences are misaligned, and this should be identified early in the encounter.