2142 Shared decision-making on treatment escalation planning in the acute medical setting for older patients: a qualitative study

Abstract Introduction Shared Decision-Making (SDM) is increasingly expected in most aspects of UK medical practice and can be particularly important for older patients to guide goals of care. Treatment Escalation Plans (TEP) summarise medical intervention to be attempted in the event of acute deterioration. Current guidance advocates SDM in TEP but it is unclear whether this is considered practicable by clinicians. This study aims to understand clinicians’ perspectives on SDM in TEP for older patients in the acute medical setting. Methods This was a qualitative study following a relativist constructivist approach. 26 consultant and registrar doctors were recruited from general internal medicine, intensive care, palliative care and emergency medicine. A clinical doctoral student conducted semi-structured interviews including vignettes of older multi-morbid patients with capacity to discuss treatment escalation. Reflexive thematic analysis was performed. Ethics approvals were obtained from the Health Research Authority 22/HRA/4387. Results Three themes were generated: ‘An unequal partnership’, ‘Options without equipoise’ and ‘Decisions with shared understanding’. SDM incorporating patient preferences with clinical opinion was seldom perceived to be appropriate. Clinical complexity and use of intuition, together with lack of perceived moral equipoise, motivated clinicians to develop medically acceptable TEPs. Shared understanding with the patient and family and avoiding conflict were important. Conclusions Contrary to current guidance, SDM was considered a potential barrier to formulating appropriate TEPs in the acute medical setting. This study suggests potential incompatibility between policies prioritising patient autonomy and the right to make unwise decisions, and those stating clinicians’ prerogative to determine realistic chance of treatment success and not provide intervention considered medically inappropriate.