• Steven Sanders, Warren J Cheung, Francis Bakewell, Jeffrey M Landreville, Cristian Rangel, Gianni D'Egidio, and Debra Eagles.
• Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario. Electronic address: ssanders@toh.ca.
• Ann Emerg Med. 2023 Nov 1; 82 (5): 583593583-593.

Study ObjectiveThe inherent pressures of high-acuity, critical illness in the emergency department create a unique environment whereby acute goals-of-care discussions must be had with patients or substitute decision makers to rapidly decide between divergent treatment paths. Among university-affiliated hospitals, resident physicians are often conducting these highly consequential discussions. This study aimed to use qualitative methods to explore how emergency medicine residents make recommendations regarding life-sustaining treatments during acute goals-of-care discussions in critical illness.MethodsUsing qualitative methods, semistructured interviews were conducted with a purposive sample of emergency medicine residents in Canada from August to December 2021. Inductive thematic analysis of the interview transcripts was conducted using line-by-line coding, and key themes were identified through comparative analysis. Data collection continued until thematic saturation was reached.ResultsSeventeen emergency medicine residents from 9 Canadian universities were interviewed. Two factors guided residents' treatment recommendations (a duty to provide a recommendation and the balance between disease prognosis and patient values). Three factors influenced residents' comfort when making recommendations (time constraints, uncertainty, and moral distress).ConclusionWhile conducting acute goals-of-care discussions with critically ill patients or their substitute decision makers in the emergency department, residents felt a sense of duty to provide a recommendation informed by an intersection between the patient's disease prognosis and the patient's values. Their comfort in making these recommendations was limited by time constraints, uncertainty, and moral distress. These factors are important for informing future educational strategies.Copyright © 2023 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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