Table 4.

Four Themes, Associated Subthemes, and Illustrative Quotations Significantly Associated with Patients Being Assessed as Receiving Inappropriate Critical Care

Themes and subthemes	Illustrative quotation
Theme: statement of goals of treatment
Statement of goals of treatment	“Pt has clearly communicated to wife that he would not like to live w/disabilities.”
	“Pts family repeatedly expressed the desire to do anything possible to keep her alive.”
	“The goal being to get the patient back home.”
	“The pt would NOT want to live a life without neurologic recovery.”
Theme: physician not guiding decision making
Default is to do more	“If family does not want feeding tube, the prognosis is poorer.”
Doctor is hopeful/optimistic	“We are continuing to be aggressive w/his care as we are hopeful we can address his severe sepsis.”
No firm recommendation given	“DW [discuss with] family regarding to make decision regarding continuing treatment trach, peg, SNF vs withdrawal of care.”
Doctor suggesting next steps disregarding improbability of steps/or improbability of recovery	“very poor prognosis…. he could be evaluated for an OLT [orthotopic liver transplant] in the future if he were to recover”
Doctor thinks prognosis is not certain enough	“Goal of care discussion with family next Monday when prognosis of patient becomes more obvious.”
Doctors pursing aggressive care to achieve an intermediate goal	“The family has been unwilling to set any limitations on aggressive therapy & thus we will proceed w/trach given that she is not weaning”
Doctor doing the wrong thing and recognizing that it is the wrong	“We placed a trach at the request of the family despite her terminal cancer.”
Theme: indecision, stalling, causes of delays in decision making
Family/patient undecided	“Daughter is undecided currently about goals of care”
Family/patient delaying decision making until time of crisis	“He is prepared to make pt DNR [do not resuscitate] if & when coding is imminent”
Family avoiding situation	“Family has not been available for meeting w/ethics, nor has the family been on daily rounds for discussion w/team”
Within family disagreement	“Daughter & husband with very different views on how to proceed & how much longer to support patient. Family needs to come to mutual agreement amongst themselves”
Awaiting family arrival	“until at least their aunt arrives from Armenia and gets to spend some time with the patient, they would like to be as aggressive with code status and care as possible”
Awaiting family meeting	“Will attempt to re-contact DPOA to update on clinical status & poor prognosis & re-discuss goals of care.”
Awaiting within-family discussions	“Requested time to communicate with siblings who live on East Coast.”
Family needs more time to make decision	“He has not yet made this decision & wants to think about it longer & discuss it w/his family”
Patient's preferences are elusive	“Patient is unwilling to communicate desires re: g-tube placement on repeated attempts.”
Family/patient needs more info	“Patient's family aware of poor prognosis. They would like to evaluate brain activity prior to changing goals of care.”
Family wants more time with the patient	“(She) understands patient will die in ICU but would like to maximize her time with mother with continued aggressive support.”
Theme: patient preference is reflected in decision making
Family acknowledging the need to focus on patient's preferences	“The son wants to seek palliative care given the pts advanced wishes to not live in a debilitated state.”
Course of care dictated by advance care planning	“…as his respiratory status continued to worsen and stridor newly developed, we discussed intubation with the family. At that point, the family decided to make him comfort care because they were clear with his advance directive that he would not have wanted intubation…”