Caring in the silences: why physicians and surgeons do not discuss emergency care and treatment planning with their patients - an analysis of hospital-based ethnographic case studies in England

Background Despite increasing emphasis on integrating emergency care and treatment planning (ECTP) into routine medical practice, clinicians continue to delay or avoid ECTP conversations with patients. However, little is known about the clinical logics underlying barriers to ECTP conversations. Objective This study aims to develop an ethnographic account of how and why clinicians defer and avoid ECTP conversations, and how they rationalise these decisions as they happen. Design A multisited ethnographic study. Setting Medical, orthopaedic and surgical wards in hospitals within four acute National Health Service trusts in England. Participants Thirty-four doctors were formally observed and 32 formally interviewed. Following an ethnographic case study approach, six cases were selected for in-depth analysis. Analysis Fieldnote data were triangulated with interview data, to develop a 'thick description' of each case. Using a conceptual framework of care, the analysis highlighted the clinical logics underlying these cases. Results The deferral or avoidance of ECTP conversations was driven by concerns over caring well, with clinicians attempting to optimise both medical and bedside practice. Conducting an ECTP conversation carefully meant attending to patients' and relatives' emotions and committing sufficient time for an in-depth discussion. However, conversation plans were often disrupted by issues related to timing and time constraints, leading doctors to defer these conversations, sometimes indefinitely. Additionally, whereas surgeons and geriatricians deferred conversations because they did not have the time to offer detailed discussions, emergency and acute medicine clinicians deferred conversations because the high-turnover ward environment, combined with patients' acute conditions, meant triaging conversations to those most in need. Conclusion Overcoming barriers to ECTP conversations is not simply a matter of enhancing training or hospital policies, but of promoting good conversational practices that take into account the affordances of hospital time and space, as well as clinicians' understandings of caring well.