P049: Goals of care discussion in the emergency department: is it possible

Abstract

Introduction: The Institut national d'excellence en santé et en services sociaux in Quebec published guidelines suggesting that emergency physicians should establish emergency department (ED) patients’ goals of care when appropriate. The objective of this study was to explore emergency physicians’ opinions about leading goals of care discussion (GCD) in their daily practice. Methods: This study used a qualitative design based on the Normalisation Process Theory (NPT); a middle-range theory used to explain the sustainability of implementing complex healthcare interventions. It was conducted in a single academic ED in Lévis, Québec. We planned to recruit a minimal convenience sample of 10 participants. Between April and May 2018, we conducted semi-structured interviews and transcribed the audio records verbatims. Deductive thematic analysis based on the NPT was conducted using Nvivo 12.0. Two authors codified the content of each interview under the four NPT macro-level constructs: coherence, cognitive participation, collective action and reflexive monitoring. A kappa score was calculated to measure the coding inter-rater reliability. Results: We interviewed 10 ED physicians (50 % women; 60% certified by the College of Family Physicians of Canada (Emergency Medicine)). No new ideas emerged after the 9th interview. Our thematic analysis identified 13 themes. Inter-rater reliability of coding was substantial (kappa = 0.72). The coherence construct contained the following themes: common concept of interpersonal communication, efficiency of care and anxiety generated by the discussion, the identification of an acute deterioration leading to the GCD, coming together of clinician, patient and family, and the importance of knowing patients’ goals of care before medical handover. The cognitive participation construct involved the following themes: lack of training on the new goals of care form and availability of reminders to promote the recommendation. One theme characterized the collective action construct: heterogeneous prioritization for leading GCD. The reflexive monitoring construct contained 4 themes: need to take action before patients consult in the ED, need to develop education programs, need for legislation and the impossibility of systematic GCD for all patients. Conclusion: Goals of care discussion is possible and essential with selected patients in the ED. Nevertheless, policy-making efforts remain necessary to ensure the systematization of the recommendation.