Making the decision to transfer an elder from the nursing home to the emergency department: The experience of key decision makers.

摘要

The specific aims of this qualitative study were to fully describe decisions to transfer nursing home (NH) residents to emergency departments (EDs), the persons involved, and how such decisions were negotiated. Three nursing homes, each in a different geographic region (urban, suburban, and rural) served as sites for data collection. Forty-two persons who participated in the decisions surrounding 16 NH to ED transfers were interviewed: 4 NH residents, 22 NH staff members, and 16 family members. Four weeks of participant observation was conducted in each setting. The interview texts and field notes were analyzed using hermeneutic phenomenological (HP) methods. At least two Key Decision Makers were involved in each NH to ED transfer decision, most often NH nurses and family members. Some participants, usually cognitively impaired NH residents, were relegated to Pseudo-Decision Maker status. Several main themes formed the framework for the NH to ED transfer decision. The acuity or novelty of the residents' complaints affected the Decision Thresholds of Key Decision Makers. When there was disagreement regarding a transfer decision, some Key Decision Members manipulated the outcome through alliances with others or by engaging in “Forceful Persuasion.” In this manner, Key Decision Makers were careful to avoid encroaching on another's Decisional Responsibility and Authority. Throughout the decision making experience, Key Decision Makers “Balanced” multiple perspectives as they “Sought Information and Guidance” from others. Key Decision Makers received information through the filter of the nurse. The theme “Knowing the Resident” permeated the decision making process and all Key Decision Makers asserted that they were making transfer decisions based on the Best Interests of the NH resident. The intents of a few Key Decision Makers were not clear, and they were suspected of “Hiding Behind the Resident.” Throughout the transfer decision, Key Decision Makers balanced multiple perspectives and transfer logistics. The potential for ethical conflicts in NH to ED transfer decisions was apparent from the findings, creating an impetus for nurses to engage in reflective clinical practice and balance the autonomy of NH residents with nurses' and others' perceptions of beneficence.