Obligated To Say “Yes”: The How and Why Behind Transfer Decisions in Moribund Patients

TL;DR

This study explores how emergency physicians decide to transfer or accept critically ill patients, revealing factors like obligation and uncertainty in predicting survival.

Contribution

The study is the first to investigate physician decision-making in transferring moribund trauma patients, highlighting new themes like obligation and advanced care planning limitations.

Findings

Physicians feel an obligation to hospitals with fewer resources when deciding to transfer moribund patients.

Prognostication is difficult and often leads to uncertainty in transfer decisions.

Current advanced care planning documents are seen as imperfect and limiting in guiding transfer decisions.

Abstract

A core principle of emergency care is the rapid transport of severely injured patients to hospitals capable of providing definitive care. Although the social, financial, and emotional factors associated with transfers, and their impact on hospital crowding, may necessitate a more nuanced approach, little has been published on how physicians actually make the decision to transfer a potentially moribund patient. We, therefore, sought to better understand these factors as the next step toward optimizing transfer flow and patient care.

We conducted one-hour, semi-structured interviews with 16 emergency physicians at referring and referral centers, including eight accepting physicians at a quaternary-care center and eight transferring physicians at community hospitals. Interviews focused on decision-making regarding interhospital transfers for moribund patients, defined as those with injuries or disease processes judged likely to be non-survivable. Interviews were transcribed and analyzed using reflexive thematic analysis to identify common themes and decision-making factors.

We identified four emerging themes that underpinned a decision to transfer or accept a potentially moribund trauma patient: 1) the accepting physician’s perceived obligation to hospitals with fewer resources; 2) the difficulty of prognostication; 3) the imperfection and limitations of current advanced care planning documents; and 4) the impact of family and patient preferences.

The rationale behind initiating and accepting transfers of moribund trauma patients is multifaceted. This study is the first to our knowledge that explores physician decision-making in this domain. Physicians feel an obligation to patients, families, and other hospitals, which leads to almost universally initiating or accepting transfers even in cases with limited hope of survival. These interviews offer insight into opportunities to improve statewide trauma operations and highlight avenues for promoting transfer-decision heuristics and pre-transfer goals-of-care conversations without compromising patient care.