title: Who Am I to Decide Whether This Person Is to Die Today? Physicians' Life-or-Death Decisions for Elderly Critically Ill Patients at the Emergency Department-ICU Interface: A Qualitative Study.
abstract: We explored physicians' perceptions of and attitudes toward triage and end-of-life decisions for elderly critically ill patients at the emergency department (ED)-ICU interface.
  
  
  
  This was a qualitative study with thematic analysis of data collected through semistructured interviews (15 emergency physicians and 9 ICU physicians) and nonparticipant observations (324 hours, 8 units, in 2 hospitals in France).
  
  
  
  Six themes emerged: (1) Physicians revealed a representation of elderly patients that comprised both negative and positive stereotypes, and expressed the concept of physiologic age. (2) These age-related factors influenced physicians' decisionmaking in resuscitate/not resuscitate situations. (3) Three main communication patterns framed the decisions: interdisciplinary decisions, decisions by 2 physicians on their own, and unilateral decisions by 1 physician; however, some physicians avoided decisions, facing uncertainty and conflicts. (4) Conflicts and communication gaps occurred at the ED-ICU interface and upstream of the ED-ICU interface. (5) End-of-life decisions were perceived as more complex in the ED, in the absence of family or of information about elderly patients' end-of-life preferences, and when there was conflict with relatives, time pressure, and a lack of training in end-of-life decisionmaking. (6) During decisionmaking, patients' safety and quality of care were potentially compromised by delayed or denied intensive care and lack of palliative care.
  
  
  
  These qualitative findings highlight the cognitive heuristics and biases, interphysician conflicts, and communication gaps influencing physicians' triage and end-of-life decisions for elderly critically ill patients at the ED-ICU interface and suggest strategies to improve these decisions.
authors.affiliation: Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France. Electronic address: thomas_fassier@uhs.edu.kh.
authors.forename: Thomas
authors.initials: T
authors.lastname: Fassier
authors.affiliation: Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Valour
authors.affiliation: Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France; Medical Information, Evaluation and Research Unit, Hospices Civils de Lyon, Lyon, France.
authors.forename: Cyrille
authors.initials: C
authors.lastname: Colin
authors.affiliation: Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France.
authors.forename: François
authors.initials: F
authors.lastname: Danet
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D016638:Critical Illness / Q000628:therapy*; D003657:Decision Making / Q000941:ethics*; D004636:Emergency Service, Hospital / Q000941:ethics*; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000941:ethics*; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research; D016414:Resuscitation Orders / Q000941:ethics / Q000523:psychology; D013727:Terminal Care / Q000941:ethics*