Ceilings of treatment: a qualitative study in the emergency department
Open accessAbstract
BACKGROUND: Decision-making concerning the limitation of potentially life-prolonging treatments is often challenging, particularly in the Emergency Department (ED). Current literature in this area of Emergency Medicine is limited and heterogeneous. We seek to determine the factors that influence ceiling of treatment institution in the ED. METHODS: We conducted a phenomenological qualitative study employing semi-structured interviews. Emergency Medicine Consultants were recruited via a sample of convenience from 5 hospitals in the West of Scotland. Data saturation was achieved after 15 interviews. Interviews were recorded, anonymised, transcribed, coded, and an iterative thematic analysis was carried out. RESULTS: A model was created to illustrate the identified themes. Patient wishes are central to decision-making. Acute clinical factors and patient-specific factors lay the foundations of ceiling of treatment decisions. This is heavily contextualised by family input, collateral information, anticipated outcome, and whether the patient is accepted for higher care. This decision-making process flows through a 'filter' of cultural and environmental factors. The overarching nature of patient benefit was found to be of key importance, framing all aspects of ceiling of treatment institution. Ultimately, all ceiling of treatment decisions result in one of three common patient pathways: full escalation, limited escalation, and maintenance of current care with the option of palliative care initiation. CONCLUSIONS: We present a conceptual model composed of 10 major thematic factors that influence Consultant ceiling of treatment decision-making in the ED. Clinicians should be cognizant of influential factors and associated biases when making these important and challenging decisions.
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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].”
From Shared decision-making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting - Observed (STREAMS-O): an ethnographic study (2025) · cites this paper as [47]
The Background defines a ceiling of treatment as the highest intervention deemed appropriate by a medical team, and the Results describe clinicians’ roles in making those decisions. But the paper does not characterize clinicians’ commitment to medical decision-making as a pervasive idea in treatment-escalation-plan research; it also says patient wishes are central and patients with capacity have final authority. (LLM, conf=0.75)
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Greenhalgh, T., Koh, G. C. H., & Car, J. (2020) · BMJ · doi:10.1136/bmj.m1182 · Cited by 705 · see citing works
Beldhuis, I. E., Marapin, R. S., Jiang, Y. Y., Simões de Souza, N. F., Georgiou, A., Kaufmann, T., Castela Forte, J., & van der Horst, I. C. C. (2021) · Journal of Critical Care · doi:10.1016/j.jcrc.2021.04.012 · Cited by 58 · see citing works
Warner, B. E., Wells, M., Vindrola-Padros, C., & Brett, S. J. (2025) · BMC Geriatrics · doi:10.1186/s12877-025-06893-7
“…was also prominent; this is consistent with other studies which have attributed conflict to clinicians’ reticence to deliver harmful, non-bene-ficial intervention juxtaposed with patient concerns that clinicians are withholding treatment, and TEP’s essentially emotional nature [14, 43, 45–47 ,”
- Authors
- Walzl, N., Jameson, J., Kinsella, J., & Lowe, D. J.
- Affiliations
- University of Glasgow (GB)
- Monklands Hospital (GB)
- Queen Elizabeth University Hospital (GB)
- Corresponding author
- Walzl, Nathan
- Venue
- BMC Emergency Medicine
- Published
- 2019-01-17
- Volume
- 19
- Issue
- 1
- Pages
- 9-9
- ISSN
- 1471-227X (ISSN-L)
- PMC
- PMC6335704
- OpenAlex
- W2912595908
- Cited by
- 26
- References
- 1
- Citations by year
- 2026: 1 · 2025: 6 · 2024: 9 · 2023: 4 · 2022: 2 · 2021: 1 · 2020: 3
- FWCI
- 1.38
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Emergency Medicine (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion, cc-by-sa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
- Health Sciences › Health Professions › General Health Professions › Ethics in medical practice
- Keywords
- life-prolonging treatment, end-of-life decisions, emergency department, patient wishes, family involvement, palliative care, patient benefit, clinician bias, conceptual model
- MeSH terms
- Clinical Decision-Making, Clinical Competence, Emergency Service, Hospital, Female, Patient Care, Humans, Interviews as Topic, Male, Risk Assessment, Qualitative Research, Patient Preference
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