Difficult conversations in the emergency department: how do senior emergency clinicians communicate with patients and relatives about serious diagnoses, palliative treatments and death? An analysis of video recordings using Conversation Analysis and development of educational resources

Research questions How do emergency clinicians engage in cifficult conversations in the emergency department and what are the perspectives of patients, relatives and clinicians with regard to difficult conversations in the ED.

Background The number of people who died in emergency departments (ED) is increasing, whilst the proportion of cancer diagnoses made in the ED is also rising.

Delivering the news of either the death of a relative or a serious diagnosis (difficult conversations) is an important skill for those working in emergency medicine, but teaching is often neglected.

The current resources available are extrapolated from non-emergency settings and there is little understanding of how these conversations develop and are navigated by emergency clinicians.

Conversation Analysis is a qualitative research tool which utilises video recordings of interactions to facilitate understanding of the complex interplay of conversation in a variety of situations. It has been employed in developing teaching resources for communication skills in end-of-life care palliative care.

Aims and objectives To understand how experienced emergency clinicians (doctors, advanced clinical practitioners (ACPs), nurses,) engage in difficult conversations with patients and relatives and detail the challenges and difficulties in these interactions To understand the wider perspectives of patients, relatives and clinicians with regards to Difficult conversations in the emergency department Methods A systematic review on the topic will be completed.

Video cameras will be installed in 5 private rooms in the ED of the Royal Derby Hospital. These are the rooms where difficult conversations are most likely to be conducted. Using the SMOTs™ system they will be recording 24 hours per day, 7 days per week. Access to the recorded material will be controlled by the Research Governance Lead for the Trust.

Staff participants will be provide consent at the start of the study period. Material containing those who have not provided consent will be deleted.

The nature of the study, the clinical conditions involved and the ED environment means that consent from patients and relatives prior to recording is not possible. Deferred consent will be sought from potential participants as part of the routine follow-up of bereaved relatives.

Those patients who receive a serious diagnosis will be approached directly on the admitting ward, up to 72 hours after discharge from the emergency department. Content will be analysed using Conversation Analysis.

The final part of the study will be a series of focus groups, involving expert and experienced clinicians, more junior clinicians and finally patients and relatives who have experience of Difficult Conversations in the ED.

Timelines for delivery September 2024-2025: Systematic review Development of study materials with Patient and Publication involvement Ethical and regulatory approvals Camera installation September 2025-September 2026 Recordings and analysis September 2026-September 2027 Focus groups Analysis Development of educational resources Anticipated impact and dissemination Findings will be published in peer reviewed journals and presented at national and international conferences.

The educational materials will be hosted by the RCEMLearning educational platform and an existing resource called RealTalk, which provides educational resources for communication in palliative care.