Communicating decisions about care with patients and companions in emergency department consultations

Abstract Introduction This paper explores doctor–patient and companion communication about care decisions in a UK emergency department (ED). Doctors interface between patients and healthcare systems and facilitate access to care across a range of encounters, drawing on information and authority to make and communicate clinical care decisions. Materials and Methods We explored characteristics of communication through ethnographic observation of 16 video‐recorded case studies of ED consultations (average length: 1 h) collected over 6 months. Companions were present in 10 cases. We conducted a framework analysis to understand the roles of doctors, consultants, patients and companions in relaying ED care decisions. Findings We present two cases to reflect companion roles and their effect on the consultation. The urgency for care and scarcity of resources means clinicians justify decisions and strategize to move patients along ED pathways. Discussion Everyday care interactions between patients and doctors are goal‐oriented and companions participate by providing case information, querying decisions and advocating for care. Our findings reflect how doctors justify decisions made in communicating the next steps in ways that characterize the clinical encounter. Conclusion By exploring everyday interactions our study contributes to a growing understanding of patient–clinician and companion communication in the ED. Patient or Public Contribution Patients and caregivers voluntarily participated in data collection and consented to video recordings being conducted of ED consultations between them and junior doctors. There was extensive consultation with all grades of staff about the acceptability of the work and the best way to conduct it to minimize the impact on patients and staff. Through this manuscript, we have demonstrated the presence and important role of companions. On reflection it would have been valuable to have included patients and companions in discussions about the work; however, this project was conducted with very limited funding and no resources were committed to patient and public involvement. Given the setting and scope of the study, it was not feasible to involve patients or members of the public in other stages of the research or preparation of the manuscript. We recognize this as a potential limitation of the work.

a practice of medical gatekeeping, which can have facilitative or restrictive aspects and are 'part of a coordinated organizational strategy for managing resource scarcity'. 5 The need 'for gatekeeping is usually underscored with three types of arguments: the need to ensure that patients receive appropriate care, the need for budget restraints and the need for justice in distributing care' 6 (author's emphasis). 'Justice' here refers to the distribution of care based on those who are most in need.
Interactions between doctors and patients are purposeful and goal-oriented, with the aim being to assess, treat and resolve the patient's case to move them through care pathways and out of ED. [7][8][9] Communication plays a critical role in this process 5,[9][10][11] and medical knowledge is constructed through a 'joint project involving patients, professionals and society, and so involves a multiplicity of gazes', 12 which extends to medical practice.
In EDs, the use of medical investigations becomes an organizing principle-legitimizing a patient's presence in the space, validating or discounting diagnoses, affording access to care pathways and treatments and making health and illness visible and invisible, present and absent. 8,13,14 Greaves 12 critiques biomedicine and biopsychosocial approaches to health and illness for their sustained fragmentation and compartmentalization in organizing medical knowledge, patient experience and services. For Greaves 12 this produces an underlying tension in integrating patients as holistic and complex people within specialized and differentiated practice and services towards common goals, arguing the result is that these tensions 'resurface continually; however, much attention is paid to overcoming them'.
Different forms of information (patient-reported symptoms and experience, physical examinations, medical investigations and the opinion of doctors, consultants and other clinical colleagues) are collated into a narrative and managed by the doctor. 8,9,12,13,15,16 The doctor needs to bring together and continually transform this narrative while accounting for wider system factors, such as capacity within the hospital and guidelines for accessing testing facilities. 1,2 While the ED is led by consultants and made up of multidisciplinary care teams of nurses, allied health professionals, care assistants, administrators and others, junior doctors are key facilitators of information flow. Junior doctors are 'front-line decision-makers' 9 in this context as they interface with and navigate between patients, consultants, clinical colleagues and wider institutional constraints in delivering care. 1 Stevenson et al. 7 argued for a nuanced understanding of what happens in EDs to identify the factors underlying patients' movement through this service. 'Citing Goodwin 17 Pelletier et al. 18   A handheld camera operated by the researchers focused on the junior doctor outside the consultation room and a microphone worn by the junior doctor throughout was used to extend observation into general ED staff interactions. 7 Care decisions are shaped by various factors, such as the complexity of the case presentation, readily available diagnoses and treatment plans, capacity within the health service and demand for care. 2,4,26 We focused on the role of the junior doctor in directing the consultation with the patient and their companions and the communication mechanisms used to determine care pathways, and navigate and relate decisions across a range of people, organizational processes and contextual considerations. 11 Our objective was to include cases that demonstrated a range of scenarios junior doctors encounter and address as frontline decision-makers in this setting. 9 The cases reflect examples of communication practices, care trajectories and pathways and roles seen across the data set.
Companions were present in over half (n = 10) of the cases in the full data set. We focused our analysis on where doctors and patients and their family members interacted over multiple encounters to establish the reason for attending, convey key decisions and resolve care in ED. 7 In the results, we present two exemplars of interaction between a patient, their family member, the doctor and a consultant in one case, and between a patient, their family member and the doctor in the other case. We demonstrate how companions influence communication with junior doctors by offering information about the patient, querying decisions made, and advocating for care. 25

| Analysis
We conducted a framework analysis, as the method facilitates the identification of patterns across cases and data and allows for the development of explanations for observations that are grouped around themes. 27 We followed the stages described by Gale et al. 27 to systematically familiarize ourselves with the data by reviewing all videos, audio recordings and transcripts of consultations between junior doctors, patients and their companions and consultants. Field notes of observations were gathered by watching the videos and reviewing transcripts. We then coded transcripts and fieldnotes to develop a working analytical framework in response to key questions related to communicating decisions about care, and roles and practices of justifying resources and access to care pathways and applied the framework to the data set. Our coding was cross-referenced for an array of case presentations, decision-making processes, care pathways and trajectories and communication between junior doctors, consultants, their patients and companions. 27 Discussions between the study team facilitated the generation of codes, themes and analysis. One researcher coded all the data, with a second researcher checking the framework alongside, which allowed for the indexing, charting, mapping and interpretation of the data and findings. 27 The framework is provided in Table A1.  Jnr Doc: Yeah. No, of course I can, and I will talk to one of my seniors, but we will only do it if they feel it's appropriate.
The doctor is not able to reassure the patient's wife about the suggested course of action and reiterates that she will speak with her 'seniors' (i.e., the consultant) and that the MRI would only be

| Case 2: Older man presenting with breathlessness
In this next case, an elderly man with breathlessness and a persistent cough has come to the ED with his wife, following a referral from his GP. The patient's wife participates in the consultation from the start when her husband defers to her to provide reasons for attending the ED as 'she's better at explaining'. This happened in other cases in the study, where companions took part in the consultation by sharing the patient's case history, current medications and immediate and relevant events leading to arrival at the ED, prompting the patient to respond to the doctor and reassuring or confirming next steps for care.
Having established the primary concern and the nature and duration of various symptoms, the doctor begins outlining the purpose of myriad tests (X-ray, echocardiogram [ECG], bloodoxygen test) and setting expectations for the experience for the patient and his wife:

| Communicating decisions to patients and their companions, and gatekeeping practices
In Case 1, the expectation that the patient's wife wants an MRI for her husband becomes a consideration for the junior doctor in taking the case forward. 11,28,29 This demonstrates the important role companions play in shaping communication in ED consultations, and how this might be received by the doctor. 25 The interjection from the patient's wife can be seen to divert the junior doctor from their goal-oriented objective of efficiently moving the patient through ED pathways. 7 The doctor moves the discussion back to the medical domain by explaining that following a 'clinical' examination, a decision will be made. The doctor also invokes the medical profession by stating that 'we'll decide', thereby positioning herself as part of a distributed network of decision-makers and acting as a gatekeeper in being the primary point-of-contact for the patient. 9,11,18,30 In this case, the clinical reason for the referral to the orthopaedic department may well support an MRI being ordered, but this request is effectively being passed on to another department. 7 Urgency for care and scarcity of resources mean clinicians justify, advocate and strategize for access to specific tests, decide to move patients into more appropriate specialist care (like orthopaedics) and communicate with patients and their families in ways that manage expectations. 5,7 Our findings reflect how doctors interacting with patients and companions in the ED continually collate and transform an array of information in reaching and communicating care decisions. 1,2 Companions can offer information about medical history, recent and related symptoms and advocate for care, for instance. They This interaction demonstrates a key role that patients' companions play in ED consultations and highlights the role of junior doctors as an interface between patients (and their companions) and broader organizational processes and systems of care that shape decisions taken in this setting. 11,18 In this instance, the complexity of care decisions and communication reflects a medical cosmology of external data in the form of test results and medical investigations being drawn into the narrative of the patient's case. 8,12,13,18 The visibility and value of specialized tests such as an X-ray and what they can show ('patchy lobes of infection') or oxygen saturation tests also reflect this hierarchy in contradicting how well the patient appears. 8 The patient's presence in the ED is justified by the route of treatment offered, particularly in being admitted for overnight care. 6 We showed how decisions about care are constituted and

| Practice implications
The contribution of this paper has been to demonstrate the important role that family members and others who accompany patients play in shaping interactions and facilitating or redirecting the flow of ED consultations by querying, clarifying and requesting further information or care from doctors. 21,23,24 Our findings reflect that doctors justify care decisions by communicating the next steps to the patient in a process to legitimize care offered in the ED that is characteristic of the clinical encounter. 14