Table 4.

Sub-themes relating to shared decision-making and holistic patient-centred care

Medical seeking behaviour	I mean social factors I would take in as well. I've worked in a country hospital and you have pretty low thresholds to scan certain people because they don't really seek medical care all the time. If you know that they come in it's probably something bad and you shouldn't just go by a single algorithm which has been run by a different [city] population with that population. P21 R
Baseline level of risk	The decision making should be not about whether they're on it [antiplatelet], but whether you think there's a risk of them having a bleed and whether you would act on that risk. … But now irrespective whether it's aspirin, [anti]platelets or [anticoagulant], it's not about that, it's about judging their risk. So that's changed- whereas previously I did have to read that line and my risk stratification was a lot higher. P3 C Frailty is independent of age. So, you can have an osteoporotic 60-year-old female which I'd scan, but you could have a fairly robust 70-year-old male that you would have a lower threshold of scanning. I think taking into account how likely you think a fracture in the individualised patient is important too. P7 C
Ability to look after themselves	So I think it's kind of tying all of those factors in together at the same time. But then also I think some of the other things that sometimes make a difference is also how safe that patient themselves is. So for example, in certain cases if they live very close to the hospital, they have a robust support system, they're capable of making sensible decisions and we know that they will be able to seek medical attention appropriately, then that sometimes gives more of a leeway of monitoring the patient rather than going straight for a scan. Especially when they're sitting on the cusp. But if we don't have those resources or they want to leave the hospital or they're socially vulnerable, there's nobody actually able to look after them to flag if they're suddenly behaving differently and need medical attention, that might lower my threshold. P3 C
Patient preferences	You do sometimes over-investigate on the basis of patient preference. In those cases you always discuss with the individual why we wouldn't scan. You tell them that there's a small but real risk that they may end up with cancer as a result of radiation injury. There are some patients that are just fixated on, whether or not it's through their own anxiety or their own issues, they're fixated on getting a test. While we're not obligated to do it, at times it's just for everyone's benefit, you just do it. P5 R sometimes in very, very difficult situations, we end up doing the scans, just for appeasing the patients. It does happen. It does happen. Because sometimes the patients are difficult and they don’t want to go and they're like ‘can I have this, I can't go to my GP’. P8 C
Consultations with family	So that would the point that I would be discussing with the family, going I don't really think this is going to be helpful, apart from delaying her transit through ED, which way would you like. I think that's completely a shared decision-making with the family and the patient. P3 C I do that in consultation with family. … I'll call the next of kin if they're not there, I'll explain to them that he might have a bleed on her brain, she is on aspirin, there are no signs of it at present and there's no reason to do a CT scan because no-one would operate on her because of her age, however if they strongly want it done, I usually do it and that's pretty much to avoid complaints and medical legal problems. But I've never had that happen. Usually I explain it to them and they say, ‘oh that's okay, we'll take nana home’ and they know if her GCS [Glascow Coma Score] drops in the next couple of days, it'll be because she's had a bleed in the brain and that that's not a bad way to go and then they go home. P6 R
Proximity from medical services	Then you also take into account patient disposition, how far away do they live from the hospital, do they have someone to look over them? …. Going back to if they do live a long way from the hospital you probably have a lower threshold to scan them given that they might not be able to present quickly in case of any change in their mental status. Then also whether or not they've got someone to keep an eye on them, just to pick up if they start acting a little bit confused and all that kind of stuff. P5 R