Discussions about Goals of Care in the Emergency Department: a Qualitative Study of Emergency Physicians' Opinions Using the Normalization Process Theory

Purpose We explored emergency department (ED) physicians' opinions about the feasibility of leading goals of care discussions (GCD) in their daily practice. Method This qualitative study was based on the Normalization Process Theory (NPT). We conducted semi-structured interviews between April and May 2018 with a convenience sample of ten emergency physicians from one academic ED (Lévis, Canada) and aimed to reach data saturation. Using a mixed deductive and inductive thematic analysis, two authors codified the interviews under the four NPT constructs: coherence, cognitive participation, collective action, and reflexive monitoring. We calculated a kappa statistic to measure inter-rater agreement. Results We interviewed 10 emergency physicians. No new ideas emerged after the ninth interview and the inter-rater agreement was substantial. Fourteen themes were identified as factors influencing the feasibility of implementing GCD: (1) interpersonal communication, (2) efficiency of care, (3) anxiety generated by the discussion, (4) identification of an acute deterioration leading to the GCD, (5) meeting of the clinician, patient, and family, (6) importance of knowing the patient's goals of care before medical handover, (7) lack of training, (8) availability of protocols, (9) heterogeneous prioritization for leading GCD, (10) need to take action before patients consult in the ED, (11) need to develop education programs, (12) need for legislation, (13) need to improve the ED environment and human resources, and (14) selective systematization of GCD for patients. Conclusion Goals of care discussions are possible and essential with selected ED patients. Physicians identified outstanding needs to normalize GCD in their practice: education for both themselves and patients on the concept of GCD, legislative action for the systematization of GCD for patients, and proactive documentation of patients' preferences pre-ED. Patient, clinician and system-level policy-making efforts remain necessary to address these needs and ensure the normalization of GCD in emergency physicians' daily practice as suggested by clinical guidelines. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement FP and PA obtained funding for the study from the Department of Family and Emergency Medicine, Université Laval. This study was also supported by an Embedded Clinician Salary Award (ECRA) awarded to PA from the Canadian Institutes for Health Research (CIHR) (#201603) and a Fonds de recherche du Québec - Santé (FRQS) Senior Clinical Scholar Award (#283211). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was conducted in a single academic ED (Hôtel-Dieu de Lévis) in Lévis, Québec, Canada, which is part of the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA). This project was approved by the CISSS-CA research ethics board (2018-487) and informed consent was obtained for all participating physicians. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Anonymized data produced in the present study are available upon reasonable request to the authors. Please note that interview transcripts were recorded and coded in French.