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Shared decision-making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting: a qualitative study of Clinicians’ perspectives (STREAMS-C)
Open accessAbstract
Background: Shared decision-making (SDM) is increasingly expected in healthcare systems prioritising patient autonomy. Treatment escalation plans (TEPs) outline contingency for medical intervention in the event of patient deterioration. This study aimed to understand clinicians’ perspectives on SDM in TEP for older patients in the acute medical setting. Methods: This was a qualitative study following a constructivist approach. Semistructured interviews with vignettes were conducted with 26 consultant and registrar doctors working in emergency medicine, general internal medicine, intensive care medicine and palliative care medicine. Reflexive thematic analysis was performed. Results: There were three themes: ‘An unequal partnership’, ‘Options without equipoise’ and ‘Decisions with shared understanding’. Clinicians’ expertise in synthesising complex, uncertain clinical information was contrasted with perceived patient unfamiliarity with future health planning and medical intervention. There was a strong sense of morality underpinning decision-making and little equipoise about appropriate TEP decisions. Communication around the TEP was important, and clinicians sought control over the high-stakes decision whilst avoiding conflict and achieving shared understanding. Conclusions: Clinicians take responsibility for securing a ‘good’ TEP decision for older patients in the acute medical setting. They synthesise clinical data with implicit ethical reasoning according to their professional predictions of qualitative and quantitative success following medical intervention. SDM is seldom considered a priority for this context. Nonetheless, avoidance of conflict, preserving the clinical relationship and shared understanding with the patient and family are important.
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Clinicians' commitment to medical decision-making is a pervasive idea in the literature, including in TEP research.
“Clinicians’ commitment to medical decision-making is a pervasive idea in the literature [14, 45–48], including in TEP research [9–14].”
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Sorted by citations
Warner, B. E., Wells, M., Vindrola-Padros, C., & Brett, S. J. (2025) · BMC Geriatrics · doi:10.1186/s12877-025-06893-7
“Clinicians’ commitment to medical decision-making is a pervasive idea in the literature [14, 45–48], including in TEP research [9–14].”
Self-citation
Metadata
- Authors
- Warner, B. E., Wells, M., Vindrola-Padros, C., & Brett, S. J.
- Affiliations
- Imperial College London (GB)
- Imperial College Healthcare NHS Trust (GB)
- Department of Targeted Intervention, University College London , London, WC1E 6BT,
- Corresponding author
- Warner, Bronwen E
- Venue
- Age and Ageing
- Publisher
- Oxford University Press (OUP)
- Published
- 2024-09-01
- Volume
- 53
- Issue
- 9
- ISSN
- 0002-0729 (ISSN-L)
- 1468-2834
- PMC
- PMC11424886
- OpenAlex
- W4402891220
- Cited by
- 8
- References
- 10
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 1
- FWCI
- 3.31
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Age and Ageing (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (submittedVersion, cc-by)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
- Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
- Keywords
- shared decision-making, older adults, emergency medicine, clinician perspectives, equipoise, patient autonomy, clinician-patient relationship, communication, moral reasoning, patient and family involvement
- MeSH terms
- Clinical Decision-Making, Decision Making, Shared, Adult, Age Factors, Aged, Attitude of Health Personnel, Female, Humans, Interviews as Topic, Male, Middle Aged, Patient Participation, Physician-Patient Relations, Qualitative Research
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