Discussions about Goals of Care in the Emergency Department: a Qualitative Study of Emergency Physicians’ Opinions Using the Normalization Process Theory
Bibliographic record
Abstract
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. Clinician’s capsule What is known about the topic? Goals of care discussions are important to provide care aligned with patients’ values and medical preferences. What did this study ask ? According to emergency physicians, are goals of care discussions feasible in the emergency department? What did this study find? Goals of care discussions are essential and possible if patient, clinician and system-level policymaking structured efforts are deployed. Why does this study matter to clinicians ? This study identified action items to improve the implementation and quality of goals of care discussions in the emergency department.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.049 | 0.076 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.011 | 0.016 |
| Scholarly communication | 0.005 | 0.007 |
| Open science | 0.002 | 0.006 |
| Research integrity | 0.003 | 0.004 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".