The stories were about interviewees’ practice or the practice of others whom they work with, and whether they perceived them to be good/wise or not so good/ unwise decisions. In order to provide an insight into our interviewees’ understanding of wise as opposed to unwise decisions, as judged by the interviewees themselves, we present the findings that relate to each of the five core elements (Table 1) and offer a different perspective on motivation.
Goals of Care to Pursue
The goals gleaned from the narratives of our interviewees were mainly that patients’ wishes are respected: treat and improve their health or preferring quality of life rather than quantity. However, there were instances when patients’ perspective “is different to our perspective as a professional” (BX12). Similarly, WX04 narrated how a patient admitted to the ward was not happy with the decision that doctors had made for him. The decision was to book the patient “for an endoscopy to change the PEG (Percutaneous endoscopic gastrostomy) [tube]” (WX04) as was requested by the care home. However, WX04 realized:
[T]hat he (patient) was not willing to have the feeding and he was willing to stop his feeding – he didn’t want the PEG reinserted again (WX04).
WX04 acknowledged that by virtue of having capacity, the patient had the right to have the tube “removed…and sent him back to the care home, [to] have food and drink as much as he can, so eating as much as he can and if he got any infection or any other problem, let him go in peace as he [patient] wanted… (WX04).
Another interviewee (BX05) narrated how a brain-injured patient was on medication that “knocked him out”. This clinical goal, thought necessary by the cardiologist, was not what this patient’s family or BX05 wanted. It was observed that medical and social goal-oriented discussions were taking place between the team looking after this patient—for them maintaining this patient’s functionality was an important goal:
Keeping the patient’s brain perfused so that he is able to function; although it may shorten life there is some quality of life” and for that it was necessary to discontinue “all the medication that might knock him off centrally, making him drowsy. I’ve got to do everything I can both medically and, from the therapy perspective, to optimise his function because that will tell us how far he can rehabilitate and where he’s going to go to after hospital (BX05).
Another interviewee narrated, in relation to another patient, that the goal of medicine should be to realize when further intervention is futile, in fact it is harming the patient:
[I]t was inappropriate to keep putting her (patient) through tests that [made] her uncomfortable…. what are we really achieving, and so, I went out and I spoke to the Registrar. He was like, “Yeah, I don’t think we should do anything for her.” Like, with the discussion with the daughter, and the grandson. I think that was the right thing to do [not to intervene] (W101-FP).
There are instances when the discordance alluded to above between the goals of care as viewed by doctors and patients, or their family, are irreconcilable and unwise decisions are made, adversely affecting the outcome. Narrating an incidence, this interviewee said:
Recently a patient was offered an operation by a surgeon that was clinically the right operation to be offered, but the way it was communicated to the patient, they have refused to have the operation. They think it’s completely not the right thing for them… (NX03).
Perception of Concrete Circumstances
Most interviewees considered that accurate perception of concrete circumstances detailing the specific practical situation at hand are important in making decisions. These circumstances would be clinical facts, social circumstances and the context in which the healthcare is delivered. Sometimes clinical facts may lead doctors to have a narrow focus of action. For instance, WX04 narrated that although he had been informed by another doctor that the patient was booked for endoscopy—“to change the PEG”—because that is what the care home requested, WX04 engaged with the patient and found:
He was – sometimes just saying ‘no’ with the head and things, so we came to the point that through our conversation, I realised that the patient has capacity, perfect capacity when you take the time to allow him to express and I acknowledged… he did not want the tube reinserted (WX04).
Others were aware of the need to consider concrete circumstances based on guidance:
So, within the WHO ICF classification there’s a very clear definition of disability- so the pathology, impairment, activity limitation, participation limitation and then contextual factors- physical structures around the person, like their caregivers etc. and the legal, contextual factors… (BX05).
Commitment to Moral Virtues and Principles
What informed these interviewees to make decisions that were for the good of the patient (in patient’s best interest), was commitment to professionally driven virtues and principles. In this regard, the following virtues were gleaned from the interviewees’ narratives: respecting patient’s values, interpersonal communication, a balanced holistic approach, recognising limits to treatment, seeking advice and courage.
Respecting Patient’s Values
Most interviewees considered respecting patients’ values and beliefs as important:
A huge part in my decision making is influenced by I think the patient’s values and beliefs, and the family’s values and beliefs as well (BX01).
Being farsighted and spending time to try and understand what is it that the patient really wants is helpful:
So, I discussed with him and I really get to that information; it took me obviously more than ten minutes… [and because] that was his (patient’s) decision, with capacity, after talking to him…. I got to what the patient really wanted to happen; I respect that, and I help him in the best way possible (WX04).
Some interviewees narrated experiences where the doctor was unable to communicate to the patient a procedure (or treatment plan) that was probably the right intervention. Poor interpersonal communication resulted in distrust and the patient refused a beneficial intervention:
…. the way it was communicated to the patient, they have refused to have the operation. That made me think well, this doctor could be fantastic in terms of his clinical acumen but if his communication is not there, well, that’s not going to give a favourable outcome (NX03).
Interviewees considered that constructing a holistic view of the patient as a person was essential. Patients are not a body that requires readjustment of the biochemical milieu, nor is the patient divided into organs working in isolation, as BX05 reiterated:
[W]e have a holistic view of the whole person, so they’re not just a heart that’s been damaged with the rest of the body attached to it; we’ve got to look at the whole picture… that really is another way of saying the holistic biopsychosocial model (BX05).
A senior doctor, it was observed, sat down with a foundation year doctor, at her suggestion, to discuss another older patient with complex health and social problems.
Recognizing Limits of Treatment
W101-FP narrated how continuing to treat a patient was not “achieving” anything; actually, it was harming the patient. Another narrated a similar experience:
For me, it's about the cost of suffering, prolonging a life where… And we get questioned a lot …..Well, we can see the situation's futile, why don't we withdraw sooner? (BX12).
While another interviewee praised how a consultant they worked with “seem to be very good at seeing problems, seeing multiple solutions, and making decisions and plans that work in different situations” and so made prompt alternate treatment plans:
So, [the] consultant will go on a ward round say, ‘I think we should do X, but if when we do X this happens, do Y, and if that doesn’t work then we’ll do Z.’ And I feel like they are wise and thought out decisions. So, I think maybe they can see the outcome of the decision that they make in the future, and how that relates to everything else (BX01).
There were those who were of the view that discussing with senior doctors and /or peers helps to achieve a good end:
He [registrar] reviewed the patient, and we got the Medical Registrar as well, who came in and saw her, and he was, kind of, the most senior medical person there at that point, ‘cause it was during the night, and he made the decision. He was like, “Yeah, I don’t think we should do anything for her.” I think that was the right thing to do (W101-FP).
It was also observed that mutual support and compassion were on display in circumstances where a lot of rapid decisions were being made.
Narrating an incident where an emergency medicine Consultant made a decision that challenged the decision of other doctors regarding a post-cardiac arrest patient, WX09 was of the view “that emergency medicine consultant actually did make a wise ethical decision for that patient by playing “What if -?” and though WX09 was not initially in agreement with this consultant’s decision admired the consultant’s courage to do what was right for the patient:
So, for a good ethical decision, that emergency medicine Consultant absolutely challenged how I viewed that patient and I would like to think it’s probably changed how I view other patients in the future (WX09).
Deliberation to Integrate Concrete Circumstances, Moral Principle/Virtues to Achieve the ‘Good End’
An important element in reaching a wise decision is integrating the particular circumstances of the case with the best interest of the patient whilst being guided by principles or virtues. This, though challenging, results in a good decision:
So what I need to do is try and optimise his [patient’s] health in general to enable his brain to function as well as it possibly can… Then look at modifying the factors around him, so looking at whether it’s too noisy, whether he gets communication in the right way, all those sorts of things. But the essential thing is getting him as fit as possible (BX05).
To make good ethical decisions some flexibility is required, otherwise:
If you have already in your mind motivated to do a particular thing, then the conversation probably becomes biased, so sometimes you just go with the open mind, and then with the conversation with the patient, you think what would be the next step (BX04).
W101FP had the foresight to predict the course of a decision taken and integrating all aspects decided:
[T]o make him [Registrar] see that side of it, and he (Registrar) agreed. He (Registrar) reviewed the patient… [The decision made should have] “been made as soon as they came in to hospital; of not to do any more, and to make them comfortable. And then as soon as that decision was made, everything just became a lot calmer, and the family were happier, the patient was happier. It was just a shame that it took, kind of, the whole day for that to happen (W101FP).
This then makes one realize that a good medical decision and an ethical decision are intertwined:
Was it a good ethical decision or was it just good medicine?… is a bit of a challenge but it probably became good medicine because it was a good ethical decision (WX09).
Motivation (to Initiate the Process and to Act to Achieve the Conclusions Reached by the Process of Deliberation)
Interviewees seemed to be constructing motivation at all stages of the process which suggests that they felt this was an important and pervasive part of a phronesis -based approach. Motivators mentioned include best interest of the patient, goodwill, avoiding harm, respecting the patient’s (or the family’s) autonomous decision and engage with the process to act on the decision made.
For example, looking at motivation and goals. In circumstances such as those narrated above where the clinical goals clashed with the goals considered important by the patient (or the family) many interviewees, motivated to act in the patient’s best interest, engaged with the phronetic process (see Tables 2, 3)
There are times when the goals to do what is good for the patient and the goals of the organization are divergent. WX04 narrated how he, in the face of disagreements with the organization and colleagues, was motivated to decide in his patient’s best interest:
So, as a decision-maker we are pushed [in] different ways … our organisations pulling from us, the patient, the family, we have our own knowledge…. they are pulling in different directions. Sometimes they are all in the same direction which is good and that makes it easy in these cases, but sometimes they are pulling in different directions…I go for what was best for the patient and [in] agreement with the patient (WX04).
Motivation is constructed at the outset of the ethical decision-making process:
“You need to have the desire, the motivation, to do a thing, then you're led to make that decision” (BX04). The rationale for not delaying and being motivated to act is included in this further excerpt:
Lots of factors that come into play. It’s what the situation is, what is the state of the patient, where if I don’t make a decision, what will happen to the patient, basically? What will be the consequence of the decision that I will be making? If I don’t make a decision, then if I delay the situation, what would happen to the patient? (BX04).
The motivational force of “doing good” and “best interest” holds traction with others too e.g. participants in our follow-on project stated that:
You have to be motivated in the first place to try to get to the right decision…. then motivation comes in recurrently [throughout] the process, because what you think is the best decision in the circumstances, that may not be what the organisational best decision might be- so all they really care about is hitting a target, they kind of don’t care how you get there. So, there are pressures on staff to perform and to make certain decisions, which are not necessarily congruent with good patient care” (Int3-02). Furthermore: “It is essential to do what is in the best interest of the patient and for this it helps to be able to understand your values, so you are motivated to do the right thing for the patients (Int3-02).
In these circumstances, some doctors were of the view that one must be motivated at the outset to engage with the patient and have the courage to act in the best interest of the patient.
BX05, motivated by the best interest of the patient, thinks in terms of the biopsychosocial model  wherein interaction between biological, psychological, and social factors calls for a holistic decision: BX05 realized that although the cardiologist’s medication will improve the patient’s long-term outcome from a cardiac perspective, the patient’s functionality was markedly compromised, which prompted BX05 to say to the cardiologist (who was also looking after the same patient):
Actually, we’re stopping some of your medication. We accept it may, on average, result in a shorter lifespan but if it’s something that’s going to keep his blood pressure at a level that keeps him cerebrally perfused and able to function then he’s got quality (BX05).
Other interviewees also narrated that “for as long as [they’ve] known the health service there is a huge level of goodwill”(BX10) and “enthusiasm” (NX02) where the primary motivation is “constantly thinking about what is in the patient’s best interest” (BX05) otherwise as a clinician “all you want to do is exciting procedures” (NX08).
In order to make decisions that take into account the many circumstances around the patient their motivation also comes through even to the point of moving away from clinical guidelines:
So they’re not just a heart that’s been damaged with the rest of the body attached to it; we’ve got to look at the whole picture and the cardiologists I’ve had debates with have always been very happy to take on board that holistic perspective and see the limitations of their treatment. And have not had a problem in going off protocol when there’s clearly a best interest’s issue (BX05).