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Table 2 Major themes and supporting thematic factors identified, with illustrative quotes

From: Ceilings of treatment: a qualitative study in the emergency department

Major Themes

Supporting Themes

Illustrative Quotes

Patient benefit

 

“…I work out what would be the maximal humane or tolerable treatment…”

Acute clinical factors

Acute disease process

“… if their condition was such that it was just for palliation. So if someone had, say, ischaemic bowel, I might decide that given their age and issues that they might not be for surgical intervention…”

Severity of acute illness

“…that ceiling of care process is probably there for every patient I see… it just comes to the fore when a patient is particularly sick…”

Reversibility of acute illness

“…something that was entirely reversible, I wouldn’t even ask the family’s opinion prior to getting them admitted to intensive care.”

Patient level of care needs

“I tend to start at the top and decide whether or not somebody who is sick is for intensive care, and I work my way down until I get to a ceiling…”

Patient specific factors

Trajectory of chronic illness

“If the patient has terminal cancer I may decide… if they’re coming in with respiratory failure from a chest infection… I’m not going to proceed to intubation.”

 

Past medical history

“Given their past medical history… you’re coming to the conclusion that the patient is never going to intensive care…”

Comorbidities

“…this presenting complaint already has a high mortality attached, but in this patient’s case, who has a lot of comorbidities, it’s going to be even higher…”

Age

“I think with younger people, so under 75, we tend to be more aggressive as a whole, but if I’ve got a well-functioning 86-year-old then it doesn’t play a role…”

“I think age comes into it… it probably shouldn’t but it definitely does.”

Functional capacity

“If you’ve got a very unwell, chronically sick, debilitated 20-something year old, your ceiling of care might be lower than that of a much older patient who is physically very fit…”

Independence at home

“… somebody who is in a nursing home… are very much delineated markers for what level of care would be placed.”

Quality of life

“Do they still enjoy something? If that’s watching the tennis or just going out into the garden… if they’re not getting any of that, what are we trying to achieve?”

Anticipated outcome

 

“There was no dispute in his diagnosis, the boy was going to die. It’s where, who with, and under what circumstances he was going to pass away.”

Accepted for higher care

 

“…you can talk about the medical things you can do, but the neurosurgeon made the decision for you.”

“…a decision that’s already made by the intensive care doctors, if they’ve had one admission… It will occasionally be documented that the patient will not be accepted for intensive care treatment again.”

“I’ve worked across England, and ICUs are quite individual things… some ICUs just have very different levels for admission…”

Patient wishes

 

“We’re not going to put them on NIV because the patient has decided they never want that again…”

Family input

 

“…then the ceiling of care is determined by the next of kin… we would potentially disagree with it… but you’ve got to involve the families.”

“we obviously use them [family], but it’s usually a clinical or medical decision… sometimes their expectations are far from realistic…”

Collateral information

Patient’s GP or specialist input

“Depending on who’s around and what time of day it is, I might phone the GP… a clinician that’s been involved in their care…”

Previous healthcare interactions

“You’ll find out their end-of-life decision making process because…you’ll read up what’s happened in the clinics…”

Documented CoT decision

“…all I needed to do was follow the plan that had been previously agreed…”

Cultural factors

Physician values

“I would want my child no matter what… that was the right thing to do…”

“There are some people that would continue to resuscitate…and just don’t want patients to die. With the best will in the world they will decide to keep going… and I’m not one of them.”

Physician experience

“You’ve made that decision before…it’s an easier decision to make…”

ED team input

“I make these decisions with the team looking after them. If a nurse has been looking after one patient for six hours… they’ll probably know more about… the whole package that goes with them than me…”

“…working in a team that doesn’t function well… might lead them to change their decision-making process…”

Environmental factors

Resource factors

“…there are only a finite number of resources... ICU is no different, they’ve got a finite number of beds. And that may rightly or wrongly play a part.”

Time related factors

“It’s very time consuming for us, practically, so if we say we’re going to palliate someone at home… most of the time it’s impossible because a lot of our work is out of hours, and palliative care and primary care is 9–5, Monday to Friday.”

“I think if it had been four in the morning she’d probably have gone down the same route I had, but when you get… a standby call at 7:40… you’re switched off and concentrating on not falling asleep…”

  1. ED Emergency Department, NIV non-invasive ventilation, GP general practitioner, CoT ceiling of treatment, ICU intensive care unit