Why are some ReSPECT conversations left incomplete? A qualitative case study analysis.

Background: As an emergency care and treatment planning process (ECTP), a key feature of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is the engagement of patients and/or their representatives in conversations about treatment options including, but not limited to, cardiopulmonary resuscitation (CPR). However, qualitative research suggests that some ReSPECT conversations lead to partial or no decision-making about treatment recommendations. This paper explores why some ReSPECT conversations are left incomplete. Methods: Drawing on observation and interview data collected in four National Health Service (NHS) hospital sites in England, this paper offers an in-depth exploration of six case studies in which ReSPECT conversations were incomplete. Using thematic analysis, we triangulate fieldnote data documenting these conversations with interview data in which the doctors who conducted these conversations shared their perceptions and reflected on their decision-making processes. Results: We identified two themes, both focused on 'mismatch': (1) Mismatch between the doctor's clinical priorities and the patient's/family's immediate needs; and (2) mismatch between the doctor's conversation scripts, which included patient autonomy, the feasibility of CPR, and what medicine can and should do to prolong a patient's life, and the patient's/family's understandings of these concepts. Conclusions: This case study analysis of six ReSPECT conversations found that mismatch between doctors' priorities and understandings and those of patients and/or their relatives led to incomplete ReSPECT conversations. Future research should explore methods to overcome these mismatches.