• Lesley A Henson, Irene J Higginson, Barbara A Daveson, Clare Ellis-Smith, Jonathan Koffman, Myfanwy Morgan, Wei Gao, and BuildCARE.
• Faculty of Life Sciences & Medicine, Division of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.
• BMJ Open. 2016 Nov 2; 6 (11): e012134.

ObjectiveTo explore the decisions of people with advanced cancer and their caregivers to seek emergency department (ED) care, and understand the issues that influence the decision-making process.DesignCross-sectional qualitative study incorporating semistructured patient and caregiver interviews.MethodsBetween December 2014 and July 2015, semistructured interviews were conducted with 18 people with advanced cancer, all of whom had recently attended the ED of a large university teaching hospital located in south-east London; and six of their caregivers. Interviews were audio recorded, transcribed verbatim and analysed using a constant comparative approach. Padgett and Brodsky's modified version of the 'Behavioral Model of Health Services Use' was used as a framework to guide the study.ResultsIssues influencing the decision-making process included: (1) disease-related anxiety-those with greater anxiety related to their cancer diagnosis interpreted their symptoms as more severe and/or requiring immediate attention; (2) prior patterns of health-seeking behaviour-at times of crisis participants defaulted to previously used services; (3) feelings of safety and familiarity with the hospital setting-many felt reassured by the presence of healthcare professionals and monitoring of their condition; and, (4) difficulties accessing community healthcare services-especially urgently and/or out-of-hours.ConclusionsThese data provide healthcare professionals and policymakers with a greater understanding of how systems of care may be developed to help reduce ED visits by people with advanced cancer. In particular, our findings suggest that the number of ED visits could be reduced with greater end-of-life symptom support and education, earlier collaboration between oncology and palliative care, and with increased access to community healthcare services.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

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