137Discharge Decision-Making For Older People In The Acute Medical Unit - An Ethnographic Study

Abstract

Health care policy consistently reflects the need for increased involvement of patients and relatives, or a shared decision-making approach in the care decisions of older people. It has been proposed that these approaches will improve patient experience and efficiency in acute care and discharge planning for older people. Despite this, poor discharge experiences for older people with a lack of involvement are consistently reported and receive much public, clinical and academic attention. This doctoral project synthesises policy and research to date and aims to explore and understand the processes by which discharge decisions are made for older people returning to the community from an acute medical unit in the English NHS. An ethnographic approach was used across two research phases. The first phase focussed on older patients’ experiences of discharge decision-making. The second phase focussed on the practice of discharge decision-making. Methods used included observation, interviews with patients and relatives, group interviews with professionals and the collection of documentary evidence. Data were analysed using the constant comparative method. Findings indicated that there was no conceptual space for shared decision-making to occur on the unit and that care was punctuated by an ingrained pace focus. Health professionals prepared for the battle of discharge decision-making, patients felt guilt and illegitimacy and relatives were put upon to support discharge. It was concluded that the AMU had a rigid temporal structure that lacked flexibility for shared decision-making to take place and for the complex needs of older people to be fully acknowledged. This structure was continually reinforced by targets and policy. For improvements in the uptake of patient-centred care initiatives, such as shared decision-making, and for improved experiences of discharge decision-making, existing policy needs to be reconsidered.