Life In The Slower Lane

Introduction and Background

Emergency departments (EDs) are fast-paced, high-stakes environments that foster a “treat first, ask later” ethos. Clinicians are trained to stabilise and investigate patients immediately, an approach reinforced by institutional norms such as rapid throughput targets and 4-hour benchmarks. This culture, while life-saving in traumas, myocardial infarction and strokes, can inadvertently discourage pausing for patient-centred conversations about goals of care. The problem becomes acute in the care of cognitively impaired older adults, such as those with dementia or delirium. These patients often cannot articulate their preferences, and in the absence of explicit advance directives, aggressive interventions (such as intubation, invasive lines, and comprehensive tests) become the default. Frontline clinicians may feel morally uneasy in such cases – aware that interventions could prolong suffering without benefit – yet feel pressured by ED norms to “do everything”.

Research confirms a mismatch between ED clinicians’ recognition of the importance of goals-of-care discussions and the realities of practice. In a survey of emergency physicians in Canada, 92% agreed that goals-of-care (GOC) conversations fell within their scope, and 96% felt comfortable with the concept in principle, yet 66% still found these discussions difficult to initiate(1). Time pressure was the most commonly cited barrier (46% of respondents), followed by the chaotic environment of the ED and a lack of prior patient relationships(2). Over half of physicians believed that someone else – usually the inpatient team – should be primarily responsible for GOC conversations. This highlights role ambiguity: ED providers recognise that such conversations are necessary, but institutional conventions and team hierarchies leave it unclear whose role it is to initiate them, especially during an acute visit. As one emergency doctor lamented, conversations about end-of-life preferences “should have occurred with their physicians sooner but [were] avoided and left to us to initiate”. In practice, many ED clinicians revert to focusing on immediate medical management, implicitly deferring or bypassing the conversation in favour of urgent investigations and treatments.

ED culture and team dynamics strongly shape these behaviours. Studies of palliative care in the ED note that traditional emergency training emphasises resuscitation and rapid intervention, such that providers “may not consider [palliative conversations] as part of their overall mission”(3). Deeply ingrained norms prioritise the speedy “disposition” of patients – getting patients admitted, discharged, or transferred quickly is seen as a mark of efficiency and success. Under this norm, taking extra time to discuss an elderly patient’s goals or to call family can feel like deviating from the ED’s purpose. Indeed, deviating from the usual rapid decision-making process can feel risky or even subversive to ED clinicians, who fear that slowing down might allow a patient to deteriorate, create workflow bottlenecks, or invite second-guessing. Hierarchies also play a role: senior doctors are more likely to engage in end-of-life discussions than junior residents, indicating that juniors often await permission or guidance from superiors(4). 

Furthermore, nurses and allied staff may recognise the need for a goals-of-care discussion yet defer to physicians due to the hierarchical structure. In contrast, physicians may assume someone else (admitting teams, primary care physicians, or families) will address it. These ambiguities can result in the issue being overlooked or not addressed promptly(5).

The consequence is that “conversations-before-investigations” – meaning proactive dialogue about patient values, goals, and comfort before reflexively ordering tests or aggressive treatments – are often missed opportunities. This is particularly problematic for cognitively impaired older people, many of whom present from residential aged care homes or with advanced chronic illnesses. Without conversations, ED teams may perform exhaustive diagnostics and interventions by default, even when outcomes are poor. (For example, roughly one-third of older adults intubated in the ED do not survive to discharge, yet if incapacity precludes discussing code status, intubation remains the “standard of care” at the moment.) Such scenarios can lead to interventions that are misaligned with the patient’s true wishes, moral distress for clinicians, and unnecessary healthcare costs – all indicators of a system in need of change.

Meanwhile, the need for improvement is pressing. With aging populations, EDs are seeing more patients with dementia and frailty each year. Recent consensus recommendations highlight that people living with dementia are at heightened risk of substandard care in emergency settings and call for research into better communication strategies and decision-making practices for this vulnerable group(6,7). In other words, the time is ripe for rethinking ED culture and practice to serve cognitively impaired older adults in crisis better. This PhD project is motivated by that need and by firsthand practical insights. In particular, the author’s leadership in the CAREPACT program (Comprehensive Aged Residents Emergency & Partners in Assessment, Care, and Treatment) has demonstrated the value of bridging emergency and aged care services(8). CAREPACT is a hospital demand management program in Queensland that provides geriatric specialist acute care and collaborative care planning for nursing home residents, aiming to reduce unnecessary emergency department transfers and improve the quality of care. Through this experience, the author observed that many emergency transfers of frail elders could be avoided or better managed if proactive conversations and advanced care plans were in place. The practical successes and challenges of CAREPACT provide a real-world foundation for this proposal, illustrating both the feasibility of alternative approaches (e.g., treating in place or streamlining ED care according to patient goals) and the cultural inertia that must be overcome in acute care settings. Thus, this research will build on those lessons, combining empirical observation with philosophical analysis to chart a path toward cultural change in emergency medicine.

In summary, this PhD project will investigate how ED culture, norms, hierarchies, and language affect clinicians’ ability to initiate “conversations before investigations” with older, cognitively impaired patients and how integrating philosophical perspectives can illuminate and improve this aspect of practice. It addresses a critical gap at the intersection of clinical medicine, ethics, and organisational culture: how can we equip and empower ED teams to pause and communicate, despite uncertainty and pressure, to ensure care aligns with patient values? Below, we outline the guiding framework for addressing this question, including the specific aims and research questions, as well as a detailed plan for an empirical yet philosophically grounded inquiry that will yield both theoretical insights and practical recommendations.

Theoretical Framework: Pragmatism, Stoicism, and the Framing of Uncertainty

A distinguishing feature of this project is its integration of philosophical perspectives, particularly the pragmatic and Stoic traditions, into the analysis of ED decision-making under uncertainty. These frameworks will serve as lenses to interpret clinicians’ thought processes and actions and as ideals to guide potential cultural reforms.

Pragmatic philosophy, as developed by thinkers such as Charles Peirce, William James, and John Dewey, centres on the idea that the meaning and truth of ideas emerge through their practical consequences and usefulness in real-life situations(9). In the context of emergency care, a pragmatist lens encourages us to ask: What are the practical outcomes of our current habits (e.g. reflexively ordering tests) versus an approach that begins with conversation? Pragmatism is inherently comfortable with uncertainty and experimentation. Dewey, in The Quest for Certainty, warned that a “single-minded quest to eliminate all uncertainty is not only doomed but destructive,” often born of fear and that we must instead embrace the “reality of the uncertain” and adopt self-correcting inquiry. This insight is strikingly applicable to emergency medicine. ED clinicians often express a desire to “rule out” every possible worst-case diagnosis – an understandable impulse given the stakes, but one that can lead to over-testing and over-treating as a hedge against uncertainty. A pragmatic approach would urge focusing on what is most likely and most meaningful for the patient, accepting a degree of uncertainty while actively learning from each case. It implies that clinical decision-making should be treated as a form of inquiry, where hypotheses (e.g. about patient prognosis or preferences) are tested through dialogue and experience rather than mindlessly following protocol or fear-driven “just in case” interventions.

Pragmatism also highlights the role of habits and environment in shaping action. Our “cognitive scaffolding” – the mental models and tools we use – and the “affordances” of our environment strongly influence what we do without explicit deliberation. In an ED, for example, the electronic order set for chest pain enables clinicians to select a comprehensive panel of tests, monitors, and alarms, facilitating immediate medical responses. The entire workflow scaffolds clinicians to think in terms of rapid diagnosis and disposition. By contrast, there are few built-in affordances for pausing to talk: no automatic prompt on the computer asking about goals of care, and often no quiet space readily available for a family meeting (clinicians cite the lack of private, quiet rooms and constant interruptions as environmental impediments to serious conversations). Language is part of this scaffolding, too. If an elderly patient is labelled a “critically ill code stroke”, every team member mobilises for immediate interventions; if the same patient were labelled “comfort care”, a very different set of actions would ensue. Clinical labels, jargon, and narratives thus frame clinicians’ perceptions and affordances – yet these labels can sometimes obscure patient context. For instance, referring to an older nursing home resident simply as “NFR, bed 5” (Not For Resuscitation) might truncate further discussion, whereas calling them “Mrs Jones, here from her nursing home without family, advanced dementia” invites a more person-centred consideration. The pragmatic lens will help analyse how such linguistic and cultural framing either constrains or expands the perceived options (affordances) for action that clinicians have in the ED. By understanding these habitual cognitive responses, we can explore how to introduce new affordances (for example, a protocol that prompts any nursing home resident’s chart to verify goals of care upon arrival, thereby scaffolding the conversation as a regular part of ED assessment).

Stoic philosophy, originating with thinkers such as Epictetus, Seneca, and Marcus Aurelius, offers a complementary ethical and psychological perspective(10). Stoicism teaches the cultivation of wisdom, courage, justice, and temperance, emphasising rational judgment and acceptance of what lies outside one’s control. In the maelstrom of the ED, stoic principles can illuminate the emotional and moral terrain clinicians navigate. One relevant Stoic concept is the dichotomy of control: clinicians cannot control ultimate outcomes (such as who lives or dies or the trajectory of an incurable illness), but they can control their judgments and actions in the moment. This is particularly salient when deciding whether to pursue maximal interventions or to have a difficult conversation about end-of-life wishes. Stoicism would encourage the physician to act according to their best rational understanding of the patient’s good, unperturbed by fear of litigation, criticism, or personal failure since those lie largely beyond one’s control if one has acted with integrity. Importantly, the Stoics warn against being ruled by passions or rash impressions. Epictetus and others emphasised the importance of pausing to question initial impressions before acting, using reason as a guide. In emergency medicine, this translates to having the fortitude to pause even when adrenaline and anxiety push one to “do something now.” It takes courage to say, “Let’s hold off on that CT scan until we talk to the family,” especially if the culture equates action with competence. A Stoic-informed view frames this courage as a virtue: the physician is exercising wisdom (practical judgment) and courage (doing what they believe is right for the patient despite pressure). As one modern clinician observed, “It is altogether too easy to forget one’s faculty of reason in the face of stress and resort to emotions or instincts… The ancient Stoics warned against succumbing to a false impression and then acting too quickly on a whim.”. This admonition could be a guiding mantra for ED providers facing uncertainty: don’t let fear or habit dictate care; pause and apply reason.

Stoicism also promotes resilience and the effective management of one’s emotional responses. ED professionals often encounter moral distress (e.g. feeling it is futile to put a frail older person on life support yet doing it anyway) and burnout from the constant pressure. Stoic practices – such as reflecting on worst-case scenarios to reduce fear or focusing on the virtue of one’s intentions rather than external validation – may help clinicians cope better with the inherent uncertainties and occasional tragic outcomes in their work. By analysing interviews and observational data for signs of emotional coping and moral conflict, we can apply Stoic concepts to interpret how clinicians either succeed or struggle to align their actions with their deeper values. For example, if a resident describes feeling paralysed by the fear of missing a diagnosis (and therefore over-orders tests), we can discuss this in terms of Stoic vs. non-Stoic reaction: the Stoic-minded approach would acknowledge the uncertainty, do one’s due diligence, but accept that no one can achieve 100% certainty – beyond that, one must let go of the anxiety of error. This relates to pragmatism and Dewey’s point: insisting on absolute certainty (or zero-risk medicine) is destructive. A philosophical synthesis of pragmatism and stoicism thus provides a powerful grounding: pragmatism guides how to think and learn in action (focus on outcomes, adapt, accept uncertainty as reality, continually inquire), while stoicism guides how to manage oneself (focus on virtue and reason, not on fear, maintain equanimity amid chaos).

In addition to these two main traditions, the project will draw on concepts from the philosophy of language and cognitive science to the extent that they illuminate how ED clinicians construct reality through words and routines. We will examine how metaphors and narratives in emergency medicine (e.g., “battlefield medicine,” “the next patient in the queue,” and “fix-it mentality”) shape providers’ mindsets. We will also utilise the concept of the “extended mind” – the idea that cognitive processes are distributed across people, tools, and the environment – to understand how decision-making is not just an individual cerebral act but a distributed activity shaped by team communications, charts, devices, and spatial layout. For example, a senior doctor’s presence and tone can extend a junior’s decision process (either encouraging a conversation or, conversely, signalling that “we don’t have time for that”). By appreciating these dynamics, we can better diagnose where interventions might disrupt harmful patterns or introduce beneficial new practices. In essence, the philosophical framework for this study offers a language for analysing the subtle, often invisible factors (beliefs, values, tacit norms) that underpin clinical behaviour. This will enrich the empirical investigation and ensure that our findings are not only descriptive but also critically interpretive – uncovering not just what happens and why but how it ought to change in light of reasoned principles.

Research Aims and Questions

Aim: To investigate how ED culture and team dynamics affect clinicians’ ability to initiate compassionate, patient-centred “conversations before investigations” (especially with cognitively impaired older adults) and to develop a philosophically informed understanding that can drive practical changes in policy, training, and culture.

From this overarching aim flow several specific research questions (RQs):

• RQ1: Cultural Norms and Barriers – What institutional norms, routines, and tacit cultural expectations in the ED influence clinicians’ willingness or reluctance to engage in goals-of-care or end-of-life conversations before ordering tests and treatments?
  • Sub-question: How do factors like time pressure, physical environment, and performance metrics (e.g. throughput targets) act as barriers or facilitators to such conversations?
  • Sub-question: In what ways do language and labels used in the ED (for example, how patients are categorised or how cases are presented during handover) shape clinicians’ cognitive framing and actions regarding investigational vs. conversational approaches?
• RQ2: Team Dynamics and Hierarchies – How do team roles and hierarchies affect the initiation of “conversations-before-investigations” in the ED?
  • Who among the team (specialists, registrars, residents, nurses, social workers) feels responsible for or empowered to start these discussions, and who hesitates due to role ambiguity?
  • How does hierarchical culture (e.g. deference of juniors to seniors or emergency physicians to admitting specialists) impact decision-making about whether to pursue a conversation or proceed with aggressive care? For instance, do junior doctors fear overstepping by initiating a goals-of-care talk, or conversely, do nurses feel it’s “not their place” to suggest that the team consider comfort-focused care?
• RQ3: Lived Experience vs. Remembered Narrative – What is the difference between how clinicians describe their decision-making regarding these conversations (in retrospective interviews) and what actually occurs in real-time practice (as observed ethnographically)?
  • What patterns or discrepancies emerge between the “remembered self” accounts (how clinicians recall and justify their actions) and the “experiencing self” evidence (their moment-to-moment behaviour in the ED)?
  • How do clinicians’ retrospective narratives frame their actions (e.g. emphasising patient factors like family readiness or system factors like busyness), and how do those narratives align with or diverge from observed reality? This question will help identify biases or blind spots in self-perception and highlight which cultural factors operate unconsciously.
• RQ4: Philosophical Interpretation and Ethical Implications – How can pragmatic and stoic philosophical frameworks help interpret the findings from RQ1–3, and what new insights do they offer about improving practice?
  • In what ways do clinicians’ decision-making processes reflect (or fail to reflect) pragmatic principles, such as adaptive learning, a focus on practical outcomes, and comfort with uncertainty? For example, do we see instances of “experiments in care”, or is there a pervasive (perhaps false) quest for certainty driving over-investigation? 
  • How do clinicians handle the emotional stress and moral uncertainty in these situations, and what stoic virtues or vices can be discerned? For instance, can we identify moments of courage and wisdom in pausing to have a conversation or moments where fear and aversion to discomfort lead to avoiding the conversation? 
  • Ultimately, how can these philosophical perspectives inform practical guidelines or training? (E.g. Could a pragmatist approach to ED ethics encourage more iterative family communication practices? Could stoic-inspired training improve clinicians’ moral resilience and willingness to make value-driven decisions?)
• RQ5: Towards Change – Methods for Improvement – Building on the above, what strategies might effectively change the culture and practice in EDs to better support conversations before investigations?
  • What do clinicians themselves suggest as solutions when prompted to reflect (for instance, do they propose interventions like dedicated palliative care liaisons in ED, simulation training, or changes in protocols)?
  • How could participatory action by clinicians be leveraged to implement changes (e.g. staff-driven quality improvement initiatives)?
  • This question will be addressed by engaging participants in co-analyses of the findings and brainstorming sessions, ensuring that both theory and the practical wisdom of ED clinicians on the ground inform the eventual recommendations.

These research questions span descriptive, analytical, and normative domains. RQ1–3 gather evidence on what is happening and why, RQ4 interprets the findings and what should be done, and RQ5 looks ahead to how this knowledge can be applied. Together, they ensure the thesis will not only diagnose the problem with rich detail but also chart a path forward.

Research Design and Methodology

To answer these questions, the study will adopt an empirical, qualitative methodology enriched by theoretical analysis. This approach is often referred to as “empirical ethics” or “embedded philosophy” in healthcare research, involving the collection of real-world data to inform and refine philosophical and ethical understanding. The choice of methods is grounded in a careful consideration of the trade-offs between a purely theoretical inquiry and an empirical one. Below, we first justify the overall approach and then detail the specific methods, including interviews, ethnographic observation, and a participatory component. We also address how the others will mitigate the limitations of each technique in a triangulation design.

1. Theoretical vs. Empirical Trajectory: Rationale for an Integrated Approach

Initially, one could imagine this PhD as a purely theoretical thesis – for instance, a philosophical argument about the nature of clinical decision-making under uncertainty, drawing on literature and ethical theory to propose how things ought to change. Such a thesis could analyse concepts (like affordances, habits, and virtue ethics in medicine) and even use published case studies to illustrate points. However, a limitation of a solely theoretical design is its detachment from the nuanced reality of ED practice. Without empirical data, there is a risk of mischaracterising the problem or proposing solutions that lack buy-in from those on the front lines. For example, a philosopher might idealise that “doctors should always take time for conversation,” which is true in principle but might ignore the practical constraints and context in which doctors operate (shift workload, lack of private space, etc.). The pure theory might also overlook the informal aspects of culture that are not documented in the literature but are felt in everyday practice (the “unspoken rules” or attitudes that an outsider can easily miss).

On the other hand, a purely empirical thesis (e.g., an ethnography or interview study of ED clinicians) could richly document what is happening but might stop short of normative analysis – it might reveal the barriers but not thoroughly interrogate the underlying value systems or imagine radical alternatives outside the current paradigm. Moreover, describing a problem does not automatically translate into solutions; a theoretical lens can help bridge that gap by asking what we should do, not just what we observe.

This project, therefore, adopts a hybrid approach: an empirical trajectory (grounded in clinical reality and capable of generating concrete recommendations) combined with theoretical depth (enabling it to challenge assumptions, integrate ethical perspectives, and contribute to the scholarship of the philosophy of medicine). This is well-aligned with a pragmatist epistemology, which holds that knowledge is best developed through an iterative cycle of action and reflection. In a sense, the study itself will be pragmatic – interacting with the field, learning from it, and reflecting on refined concepts. It is also aligned with Stoic humility: we acknowledge that we must learn from real people’s experiences (overcoming any philosophical hubris that would prescribe solutions from the armchair without listening to practitioners).

In practical terms, this means the methodology will involve fieldwork in emergency departments to gather data, followed by an interpretive analysis where the philosophical frameworks previously outlined will be used to make sense of the data. The empirical findings may even loop back to refine the theoretical framework (for example, if clinicians consistently frame decisions in terms of duty or empathy, we might integrate a virtue ethics perspective alongside stoicism; if they speak in terms of probabilities and outcomes, we reinforce the pragmatist lens).

Crucially, the ultimate goal is to produce actionable knowledge that informs policy, clinical training, and cultural reform. An empirical study provides the credibility and specificity needed for those practical outputs. Hospital administrators and clinician educators are more likely to be persuaded by evidence like, “In 60 hours of observation, we noted that not a single goals-of-care conversation occurred until after diagnostic tests were ordered, and clinicians later reported feeling ‘there was no time’,” than by abstract arguments alone. By documenting current practice and its pitfalls, we create a compelling case for change; by couching it in philosophical insight, we ensure that the recommendations resonate with core values and are not merely technical fixes.

In sum, the methodology is empirical in execution and philosophical in interpretation – a design well-suited for a PhD in health humanities or philosophy of medicine that must remain grounded in clinical reality. With this rationale established, we now describe the specific methods and how they will address the research questions.

2. Data Collection Methods

Overview: This study will employ a combination of qualitative methods:

• In-depth interviews with ED clinicians,
• Ethnographic observation in the ED environment, and
• Participatory workshops or focus groups with clinicians (as a form of member-checking and co-creation of solutions).

Using multiple methods (triangulation) will provide a comprehensive picture. Interviews will capture personal perspectives and reflective narratives (addressing RQ1, RQ2 and parts of RQ4), observations will capture actual behaviour and context (addressing RQ1, RQ2, RQ3), and participatory sessions will help validate findings and brainstorm changes (addressing RQ5 and also enriching RQ4 by getting clinicians’ reactions to philosophical interpretations).

2.1 Interviews: Capturing Clinicians’ Perspectives (and the “Remembered Self”)

We will conduct approximately 20–30 semi-structured interviews with a purposive sample of ED clinicians. This will include physicians at various levels (consultants, registrars, and residents), nurses (as they play a critical role in patient care and have insightful views on team communication), and potentially other staff members, such as social workers or allied health professionals. Sampling will aim for diversity in experience, encouraging participants from multiple hospitals if feasible (to see how culture might vary or resonate across sites).

Interview questions will explore areas such as:

• The clinician’s general approach to caring for older adults with cognitive impairment in the emergency department.
• Their experiences (good or bad) with initiating or foregoing goals-of-care or end-of-life discussions in the ED.
• Perceived barriers and facilitators to having those conversations (e.g. “What makes it hard to talk about prognosis or code status in the ED?”). We anticipate hearing themes such as time constraints, difficulty reaching family, or uncertainty of prognosis, as found in prior studies.
• Team and institutional factors: e.g. “Do you feel it’s your role to address goals-of-care, or someone else’s? Why?” (This probes role ambiguity and hierarchy influences – will they say “the admitting team or ICU should do it” as 54% did in the Canadian survey?). “How does your team handle it if, say, a junior wants to discuss comfort care, but a senior is more aggressive, or vice versa?”
• Language and framing: e.g. asking if they use specific terms or if labels like “palliative” change their approach.
• Emotional and ethical reflections: e.g. “Can you recall a case that made you uncomfortable about providing too much or too little care? How did you cope and decide what to do?” This can reveal whether they felt pressure, fear of error, moral distress, etc., linking to Stoic themes of fear versus courage.
• Improvements: we’ll ask, “In an ideal world, what would help you have these conversations more often or more effectively?” (This invites their ideas for solutions, feeding into RQ5.)

Interviews will be audio-recorded and transcribed verbatim. We will assure confidentiality and use de-identified case examples in discussion to encourage honesty. Given that interviews reflect the “remembered self” (to use psychologist Daniel Kahneman’s term), we acknowledge that people reconstruct their experiences in a narrative that might emphasise specific justifications or omit details. Clinicians might, for instance, rationalise a decision with hindsight bias or portray themselves in a favourable light (a form of social desirability). They may also genuinely misremember sequences of events due to the complexity of ED shifts.

We will treat these interviews not as perfect, factual accounts but as insights into clinicians’ beliefs, attitudes, and rationalisations – which are valuable in their own right. An advantage of interviews is that they allow us to delve into motives and feelings (things not directly observable). For example, an observation might show a physician ordering a full workup on a frail patient; the interview might reveal the physician’s internal reasoning (“I was afraid we’d miss something and get sued” or “I didn’t think the family would agree to comfort care anyway”). These insights are key to understanding the cultural mindset and personal philosophies at play.

However, the limitation is that these accounts can be incomplete or biased – hence the importance of complementing them with observation data. By comparing what clinicians say with what we see, we can identify discrepancies (for example, a doctor might assert that they “always consider code status,” yet observations might show several instances where this was skipped in a rush). Such gaps are telling: they may indicate system pressure that makes following one’s ideals difficult or blind spots where clinicians think something is happening (perhaps assuming someone else did it) when it is not.

In summary, interviews will provide a window into the ED clinicians’ worldview – their understanding of their role, their interpretation of cultural norms, and their ethical stance. This addresses RQ1 and RQ2 by directly inquiring about norms and roles and addresses RQ4 by eliciting their implicit philosophies (e.g., do they exhibit pragmatist thinking, focusing on outcomes, or do they display stoic-like acceptance or, conversely, anxiety?). It also contributes to RQ5 by gathering suggestions for improvement.

2.2 Ethnographic Observation: Witnessing Real-Time Team Dynamics

To capture the “experiencing self” of clinicians and the authentic team interactions in the ED, an ethnographic observation component will be undertaken. The researcher (the author, who is both an experienced ED physician and now a researcher) will spend extensive time observing in the ED – ideally, 100+ hours spread across different shifts (day, evening, night) and days of the week to capture a variety of conditions. These observations will focus specifically on scenarios involving older adults with cognitive impairment (e.g., triage categories that flag confusion, patients from nursing homes, etc.). Still, they will also consider general ED flow and culture to contextualise these scenarios.

What will be observed?

• Instances (or absence) of conversations about goals of care or the patient’s values. We will note when such discussions occur, who initiates them, how they are phrased, and at what point in the patient’s ED course they take place (e.g., upon arrival, after initial stabilisation, not until the admitting team arrives, or not at all). We will also note when they arguably should happen but don’t – for instance, an 85-year-old with advanced dementia is rushed to a CT scan without any discussion of the big picture.
• The language and communication used by the team. This includes how cases are handed over (“Mrs X is a 90-year-old from a nursing home with advanced dementia, now septic – we’re working her up” vs. “…we’re considering if she’d even benefit from ICU or if comfort care is more appropriate” – such differences in framing are crucial). We’ll observe if clinicians use euphemisms or avoid specific topics (e.g. not mentioning “palliative” or “dying” in the ED bay, perhaps due to cultural taboo in that setting).
• Team decision-making processes: How are decisions made when uncertainty is high? Do doctors call families or outpatient doctors for context? Is there a huddle that includes nurses? Does a consultant explicitly give or deny permission to discuss limits of care? We’ll watch for hierarchical interactions: e.g. a junior might whisper to a senior, “Should we consider not doing more?” and see the senior’s response – is it receptive or dismissive? These micro-interactions illuminate hierarchy effects.
• Environmental context: We will note conditions such as crowding, noise, interruptions, and alarms – all elements of the ED environment that were identified as barriers in prior research. For example, suppose a doctor attempts to speak with a family in the hallway and is interrupted twice by phone calls or other patients. In that case, we document this because it exemplifies how the environment hinders lengthy conversations.
• Non-verbal and informal culture: The ethnographer will pay attention to the “vibe” and unspoken rules. Is there a norm that end-of-life discussions happen only in private or only after a specific step? Are certain remarks made in passing that reveal attitudes (e.g. jokes or comments like “Another nursing home dump” or “We don’t have time to play social worker”, which would signal cultural views and potential cynicism or frustration)? Prior ethnographies of eating disorders (EDs) have uncovered rich cultural elements – such as humour, taboos, power dynamics, and coping mechanisms – which we will also catalogue as they pertain to our topic.

All observations will be recorded as field notes. To maintain confidentiality and ethical standards, no patient identifiers will be recorded, and sensitive moments (such as actual conversations with family) will be noted in summary form without quoting patient names, etc. We will obtain the necessary ethics approvals and, if required, consent from staff (and assent from patients or their families if observing interactions with them, unless waived in a minimal-risk observational context).

Being an insider (the author in their own ED), or at least a clinically knowledgeable observer, is advantageous: they will understand the medical jargon and inner workings, and clinicians may be more at ease with a colleague observing. However, observer bias and influence must be managed. If colleagues know the author as a palliative care advocate, will they alter their behaviour (the Hawthorne effect)? To mitigate this, observation will be as unobtrusive as possible. Over a long enough period, staff tend to revert to normal behaviour as the observer “fades into the background.” We will refrain from intervening in care (unless there is a safety issue) to purely observe.

We will also consider shadowing patient trajectories, following a particular patient from arrival to disposition, to observe how decisions are made and unfold. This could reveal, for example, that a conversation was deferred until the admitting medical team arrived – highlighting the interface between the ED and inpatient cultures.

The ethnographic data addresses RQ1 and RQ2 directly by providing evidence of norms, hierarchies, and role behaviour in action. It serves as the primary source for RQ3, enabling a comparison between what people reported in interviews and what occurred. For instance, if interviews universally claim that “we involve families early,” but observations show that families are often not contacted until very late, that tension will be explicitly analysed. Or vice versa: perhaps interviews downplay the role of nurses, but observation shows that nurses quietly influence decisions (e.g., a nurse asking the doctor, “Should we perhaps discuss comfort care?”).

Furthermore, the observational findings will inform the philosophical analysis (RQ4) by providing concrete scenarios to apply pragmatic and Stoic interpretations. For example, we might detail an observed case where a physician was visibly torn about intubating an older person with a poor prognosis and discuss how a stoic lens would view their internal struggle and actions.

Lastly, observation will also capture any ad hoc strategies that savvy clinicians have already used to overcome barriers. Perhaps we’ll witness a doctor pulling a family into a quiet supply room to talk (creating a makeshift private space) or using a phrase that effectively communicates prognosis. These could be golden nuggets that inform our recommendations and show that change is possible even within current constraints.

In conclusion, the ethnography will provide a rich, real-life context that grounds the study in a meaningful way. Identifying the “cognitive, environmental, linguistic, and social attributes” of the ED culture at play aligns with prior ethnographic work and extends it to this specific ethical issue.

2.3 Participatory Action Component: Engaging Clinicians as Co-Researchers

As a final methodological layer and in line with the pragmatic commitment to actionable change, the project will include a participatory action research (PAR) element. After initial data collection and preliminary analysis, we will organise one or more clinician workshops (or focus group discussions) to share the findings with participants and solicit their input on interpretation and solutions. This serves multiple purposes:

• It acts as a member-checking mechanism, validating whether the themes we identified resonate with the clinicians’ experiences and obtaining clarification or correction if needed.
• It empowers clinicians to move from research subjects to partners, potentially increasing their buy-in for subsequent changes.
• It directly addresses RQ5 by providing a forum for collective brainstorming of interventions to improve practice.

For example, we might present a summary like, “We observed that in 8/10 relevant cases, conversations about goals only occurred after blood tests or imaging. Interviewees stated that time pressure is a significant issue. Does this sound right? Why do you think this is happening? What could we do about it?” Facilitated group discussion will likely yield more profound insight into why certain things happen (“Well, often we’re afraid families will react badly, so we’d rather ICU have that talk”) and practical ideas (“Maybe we need a checklist or a quick guide for initiating these talks in ED”).

Prior research shows that staff participatory sessions can be efficient in identifying barriers and solutions, often revealing ideas that management hadn’t considered. In Cameron et al.’s ED communication study, a 3.5-hour workshop with multidisciplinary staff not only surfaced key themes, but 81% of participants reported that it would change their practice, demonstrating the empowering effect of involvement. We anticipate similar positive outcomes: clinicians may feel heard and motivated to implement the suggestions they propose.

During these sessions, we will also gently and practically integrate philosophical reflections – essentially translating stoic or pragmatic ideas into discussion prompts. For instance, we might ask, “What do you think would happen if, instead of rushing to order a CT, we took 5 minutes to talk – what are you most worried about in that scenario?” This could bring out fears (e.g. “I fear being seen as doing nothing”). We can then collectively discuss which of those fears are real vs perceived and how to mitigate them (this mirrors a stoic exercise of distinguishing what’s in our control and what isn’t). Likewise, a pragmatic angle could be: “How could we make it easier to have these talks? What small change in process or environment would afford that possibility?” The clinicians might suggest very practical affordances: e.g. “If we had a dedicated quiet room near the ED, that’d help” or “If the electronic health record flashed an alert about existing ACP documents, we’d be prompted to pause.” These concrete ideas are precisely what we want to gather for the recommendations chapter.

The output of the participatory workshops will be recorded (with permission) and analysed similarly to interview data (thematic analysis but also looking for consensus vs dissent on solutions). This will directly inform the thesis’s final chapters on recommendations. It also serves as a pilot for change: ideas from these sessions could be turned into a small intervention (outside the scope of the PhD to implement fully, but possibly to propose to hospital leadership).

Through this method, we not only get richer data but also initiate the very cultural shift we are studying: encouraging open discussion about how the ED handles end-of-life care. It signals to staff that this is a domain of care the ED should care about and can improve, countering the mindset that “this isn’t our job.” In essence, the participatory approach is as much part of the impactas it is part of the research process.

3. Data Analysis

All qualitative data (interview transcripts, field notes, and workshop transcripts) will be managed using qualitative analysis software (e.g. NVivo or Atlas.ti) for the organisation. The analysis will proceed in several iterative steps:

• Thematic Analysis: We will code the data inductively for emergent themes related to our research questions. Likely themes for barriers might include “time/throughput pressure,” “ED environment (noise/lack of privacy),” “uncertainty/prognosis difficulty,” “role expectations,” “hierarchy influence,” “emotional discomfort,” “prior advance care planning (or lack thereof),” etc., many of which have been identified in the literature. We will also code for any mention of solutions or positive deviance (instances where things went well and why). The open-question responses in prior studies, for example, identified themes like “the ED does not lend itself to quiet, thoughtful discussions” and “they don’t know us – this conversation should have happened sooner”; we expect similar themes to arise and will compare our data to such existing findings as part of validation.
• Framework Analysis using a Theoretical Lens: In parallel, we will apply a deductive coding frame derived from our philosophical concepts. For instance, we might tag references to certainty/uncertainty (do people express needing certainty?), time and decision urgency, fear/risk-aversion, professional duty or virtue language (e.g. someone saying, “I just couldn’t bring myself not to investigate – it felt like giving up” might be coded under stoic virtue ethics as tension with perceived duty), evidence of habit vs. reflection, etc. We will examine to what extent the data reflects pragmatist thinking (e.g., focus on outcomes, willingness to adapt) or the lack thereof, as well as stoic attitudes (emotional regulation or lack thereof).
• Narrative analysis: For some key cases, we may reconstruct a narrative that combines interview data and observational findings. For example, a particular patient case that was observed can be narrated with an account of what happened and then augmented by interview comments from the clinicians involved about that case. This within-case analysis can highlight how interpretation and reality match or differ.
• Comparative analysis: Compare across roles (do nurses see barriers differently than doctors? Do junior doctors feel more constrained by hierarchy than seniors? How does a high-performing ED (perhaps one known for geriatric care excellence) differ from a typical ED in these dynamics?). If multiple sites are involved, we will also compare the site cultures.
• Integration of Participant Feedback: The notes from participatory sessions will be used to refine themes and ensure that our interpretations are accurate and not misaligned with the participants’ perspectives. If participants collectively disagree with an initial analysis, we will revisit the data to understand the reasons and make adjustments accordingly.

Throughout the analysis, maintaining the chain of evidence with citations will be important for the thesis write-up. We will link assertions in our findings to specific data excerpts (using pseudonyms for participants). For example, if we state, “Many clinicians felt these conversations were ‘someone else’s job’,” we will back it up with an illustrative quote from an interview (e.g. “I think general medicine should handle that, we’re too busy in ED,” said one resident) – similar to how Argintaru et al. reported 54% believed admitting services should conduct GOC discussions.

The philosophical analysis (RQ4) will not be a separate silo but will be woven into the discussion of each theme. For instance, if a theme emerges around “fear of missing something drives over-investigation,” we will discuss that through a stoic lens (fear as a negative passion for overcoming) and through a pragmatist lens (clinging to an illusion of certainty vs. employing fallibilist reasoning). We will also explicitly discuss whether the data suggests any normative critique of ED culture: e.g. perhaps the data shows that failing to have conversations leads to moral distress and poorer outcomes, which ethically underscores the need for change – a point we can buttress with external evidence (like the known statistic of poor outcomes for specific intubated older people or the benefits of aligning care with patient wishes).

Triangulation of data sources will enhance credibility. If interviews, observations, and literature support a finding, we can be confident in it. If there is divergence (e.g. interviews say one thing, observation another), that is itself a finding to report and understand.

4. Trustworthiness, Ethics, and Reflexivity

We will ensure the trustworthiness of the qualitative research through strategies like:

• Member checking and triangulation (already described through the workshops and multiple methods).
• Peer debriefing: discussing emerging analyses with supervisors or a small advisory group, including perhaps a bioethicist and an ED clinician not directly in the study.
• Reflexivity: The researcher will maintain a reflexive journal to note their assumptions and reactions during data collection and analysis. As ED physicians themselves, they must be mindful of potential biases (e.g., an inclination to empathise with clinicians’ viewpoints). However, this insider status also grants a “cultural intuition”. By actively reflecting, they can distinguish when an interpretation is coming from the data versus from their prior notions, adjusting as needed.

Ethically, the study involves healthcare professionals as participants and poses minimal risk, primarily due to concerns regarding confidentiality. We’ll take care to anonymise data (using codes for individuals and removing identifying details of cases). For patient involvement (if observing patient interactions), we will follow ethical guidelines, possibly obtaining consent from patient surrogates when feasible or using an ethics board–approved observation protocol that balances the need to observe fundamental dynamics with respect for patient privacy. Since our focus is on clinicians’ behaviours and the cultural system, individual patient data is not our target – that helps in limiting ethical complexity, but we remain sensitive to it.

In conclusion, the methodology is designed to explore the research questions from multiple angles thoroughly. By combining interviews (self-report), observations (external report), and engagement (collaborative sense-making), we maximise our understanding of the complex phenomenon at hand. This comprehensive approach aligns with recommendations in emergency medicine research to employ mixed qualitative methods for addressing deeply rooted cultural issues. We are confident that this design will yield both the “thick description” necessary for academic rigour and the practical insight needed to inform real-world improvements.

Proposed Thesis Structure

To organise the work, the thesis will follow a structure (subject to refinement as the research progresses):

1. Introduction: An overview of the research problem and significance. This chapter will introduce the challenges in ED care for cognitively impaired older adults and define the concept of “conversations-before-investigations.” It will also state the research aims and questions and provide a roadmap for the thesis.
2. Background and Literature Review: This chapter will review relevant literature in several domains:
   • ED culture and team dynamics (including prior ethnographic studies of EDs, e.g., how culture influences practice).
   • Communication and decision-making in acute care for seriously ill older adults (covering studies on GOC discussions or palliative care in EDs, such as barriers identified: time, environment, and lack of relationships, and facilitators, e.g., availability of palliative consultants).
   • The “institutional ethos” of emergency medicine (time sensitivity, “saving lives” mentality) versus the needs of geriatric and palliative care (this will draw on emergency medicine textbooks or commentaries that discuss this tension, as well as statistics about outcomes for interventions in elderly, and perhaps cases from literature).
   • Any existing interventions or training (e.g., the EM Talk program for communication or protocols like “rapid GOC conversations” in the ED) to situate how our research can build on current efforts.
   • Knowledge gaps: highlighting that while we know general barriers, we don’t fully understand the cultural nuances (like hierarchy and language), nor have we integrated a humanities perspective in analysing them.
3. Conceptual Framework: A dedicated chapter laying out the philosophical and theoretical framework in depth. Here, we will expound on pragmatism and stoicism as they apply to medicine (with references to key philosophical works and modern interpretations). We will define concepts like affordances, cognitive scaffolding, habits, and virtues in the context of clinical behaviour. We will also clarify how we use these frameworks methodologically – essentially forming the analytic lens for later chapters. This chapter may also position the work in the field of bioethics or health humanities, for instance, by referencing clinical pragmatism in ethics consultation or the role of virtue ethics in medicine to demonstrate academic grounding. By the end of this chapter, the reader should understand how and why pragmatist and stoic ideas will inform our data interpretation and what novel angle this provides compared to a purely biomedical or social science approach.
4. Methodology: This chapter details the study design as described above. It will recount the debate between theoretical and empirical approaches (briefly, as one motivation for the design) and then explain the qualitative methods employed (including interviews, observations, and participatory workshops). It will include the setting and recruitment, data collection procedures, analysis strategy, and ethical considerations. This chapter solidifies the credibility of our approach. We’ll also note any deviations or adaptations that occurred (for example, if COVID-19 or other factors affected data collection, etc.). The strengths and limitations of the chosen methods are explicitly addressed here – for instance, discussing the potential biases of interviews (the remembered self) and how observations and participant feedback counterbalance these biases.
5. Findings – Part I: The Landscape of ED Culture and Communication. This chapter (or set of chapters) will present the empirical findings. It may be organised thematically. For example:
   • 5A. Barriers and Norms: detailing themes like time pressure and throughput, environmental constraints, lack of patient background info, and prevailing norms about what ED care entails. We will include illustrative quotes and vignettes (e.g. “During a busy evening shift, none of the five elderly patients observed had a documented goals-of-care discussion in ED. Clinicians cited being ‘under the pump’ with no time – one physician noted, ‘this is not a discussion that should feel rushed, and we are under enormous time constraints’”). We’ll also highlight norms such as “the default is full intervention unless stated otherwise” and how that is reinforced culturally.
   • 5B. Hierarchy and Roles: exploring how different team members view their roles. For instance, we might find that juniors feel reluctant to broach palliative options unless the attending physician leads the discussion or nurses think they can only hint at it diplomatically. Any observed incidents of hierarchical tension or good teamwork will be described. We will relate this to specific data, e.g. “54% of surveyed ED doctors in one study believed admitting teams should handle GOC discussions, and our interviews echoed this sentiment – e.g., a junior doctor said, ‘I admit I kind of hope the ICU team will bring it up because they have more authority with the family.’” This grounds our findings in a broader context.
   • 5C. Language and Framing: presenting findings on how patients and decisions are framed. Perhaps we’ll present a table of commonly used phrases and their implied meanings (for example, saying, “We have to get them a bed before we talk to the family” implies procedural priorities). Or how the term “palliative” is used – maybe some staff avoid it for fear families will panic, which is a finding in Argintaru et al. as well, where families assumed “they’re going to die today” once GOC was mentioned. If relevant, we’ll include that perspective.
   • 5D. Emotional and Ethical Underpinnings: what feelings do clinicians describe or display? Stress, fear of litigation, compassion, etc. This might include the moral distress theme (“I felt bad doing all that to him… but I had no choice”) or, conversely, relief when conversations happen (“It was a weight off when the daughter said she wanted no aggressive care”). This section naturally segues into the next chapter, where we analyse philosophically.

(Depending on the length, chapters 5A–5D could be separate chapters or sub-sections of one extensive findings chapter. The structure will be tailored to ensure clarity.)

6. Findings – Part II: Comparative and Observational Insights (Reality vs. Rhetoric): Here, we explicitly compare the interview narratives to observations (RQ3). We might show a few case studies. For example, Case: Mr J, 88, with advanced dementia, was brought in for pneumonia. We describe what was observed (e.g., no GOC discussion until he was intubated and the family arrived later, shocked) and then include what clinicians said about it in interviews (perhaps after the fact). This highlights gaps and reinforces where culture impeded best practices. We also incorporate any positive deviant cases (such as one scenario where an ED doctor took the time to talk first – what enabled that? Perhaps an unusually low census moment or a remarkably experienced clinician with palliative training). Those serve as exemplars to learn from. This chapter will thus sharpen the picture of what happens, as distinct from what clinicians think or hope happens. It provides a reality check that strengthens the call for change.
7. Discussion: This is a crucial chapter in which we synthesise the findings with the philosophical framework (RQ4) and discuss the implications. We will revisit each research question:
   • For RQ1 & RQ2, interpret the cultural and team dynamics in light of pragmatism and stoicism. For instance, we might discuss that ED’s institutional norm of valuing speed and “saving lives” functions almost as a moral habit that needs to be recalibrated. We’ll argue that from a pragmatist perspective, the ED should broaden its definition of a “successful outcome” to include outcomes aligned with patient values, not just physiological rescue – tying to the idea that “practical success” in medicine isn’t always cure, sometimes it is a good death or avoided suffering. We can cite Dewey or others to support the reframing of metrics of success (e.g., how current ED metrics overlook this dimension). We will also highlight how hierarchies can suppress valuable input, which is an ethical issue of voice and empowerment. Perhaps relate to Habermas’ idea of an ideal speech situation (if desired) or note that it’s counter to patient-centred care.
   • For stoicism, we’ll examine how clinicians deal with the emotions of practice. Did we find evidence of something akin to stoic resilience or, conversely, evidence of emotional overwhelm? If many avoid conversations due to discomfort, we label that as a target for improvement – courage and open acknowledgement of mortality should be cultivated as professional virtues. We might draw on modern Stoic writings for physicians that echo this. We will discuss how adopting a stoic mindset (focusing on doing the right thing by the patient, accepting that not all outcomes can be controlled or positive) could alleviate some moral distress and paradoxically improve decision-making. We’ll relate this to our data: e.g. if a doctor said, “I felt like I was failing the patient by not intubating, but also failing by intubating,” we analyse this dilemma and how reframing success (in stoic terms, success = acting with wisdom and compassion, regardless of outcome) might help.
   • We also compare our findings to existing literature: do we confirm known barriers? (Likely yes: time, environment, and lack of relationship all appear in our study just as in others). What new contributions do we make? (Perhaps a deeper understanding of role dynamics and language, which fewer studies have explored, plus the novel philosophical framing).
   • We will highlight any unexpected findings. For instance, we may find that specific terminology can either trigger or avoid conversations (for example, using the phrase “allow a natural death” may work better than “DNR” with families – a micro-level insight relevant to language).
   • Policy and Training Implications: We’ll start enumerating what needs to change. This discussion lays the groundwork for the next chapter by outlining the rationale for the proposed changes. For example, we conclude that system-level changes (like adjusting ED workflows or having specialist support) and educational interventions (like communication training and interprofessional teamwork exercises) are needed. We argue these points based on our findings (e.g., since lack of time is a barrier, policy might need to allocate time for this task; since clinicians fear prognostic uncertainty, training on communicating uncertainty is necessary).
   • The philosophical perspective also ensures we address the ethical imperative here: it’s not just about making clinicians’ lives easier; it’s about respecting patient autonomy and dignity even in emergency contexts. We’ll articulate that ethical argument, using our data to show that current practice can fall short of ideals like informed consent or shared decision-making for incapacitated patients; thus, it’s a moral and professional imperative to reform ED culture.
8. Recommendations and Conclusion: The final chapter will outline concrete recommendations for practice, education, and future research. This flows directly from RQ5 and the participatory input:
   • Policy Recommendations: e.g. Develop protocols that within the first 30 minutes of an older cognitively impaired patient’s arrival, staff must check for existing advance care directives (perhaps integrated into electronic records) and attempt to contact a surrogate decision-maker. Another policy could be to trigger palliative care consults or involvement for certain high-risk cases – the literature suggests that many ED doctors would welcome 24/7 palliative care consultants as facilitators. If our participants echoed this (which is likely), we recommend that health services invest in such resources.
   • Environmental/Systems Changes: e.g., ensure ED design includes a quiet family consultation room that is easily accessible (a seemingly small infrastructural change that addresses a barrier we identified). Or adjusting metrics – perhaps recommending that hospital leadership include quality of GOC communication as a quality metric alongside throughput to shift priorities.
   • Educational Interventions: Suggest integrating communication skills training specifically for ED scenarios, building on programs like EM Talk. Training could also involve simulation exercises where the medical “problem” cannot be solved by interventions alone, forcing trainees to practice the conversation pause – essentially, simulations of the very scenario in our opening narrative, where intubation is not clearly the correct answer and talking is indicated. We might also recommend incorporating ethics and philosophy into EM curricula – perhaps as reflective practice sessions where residents discuss cases with ethicists or utilise Stoic techniques to explore coping strategies. Notably, our study findings suggest that once taught, clinicians highly value these communication skills. We can cite evidence that, after communication training, emergency physicians felt better equipped.
   • Cultural Initiatives: Propose that ED departments develop a culture of open dialogue about these issues. For instance, regular interdisciplinary debriefs after tough cases (including discussion of what went well or not in terms of aligning care with patient goals). Perhaps designate “Geriatric champions” or “Palliative champions” within the ED team who take the lead in fostering conversations. Another idea from pragmatism is to run small Plan-Do-Study-Act (PDSA) cycles, where the ED team trials a change (such as a checklist prompt or a code status discussion routine) and evaluates it – encouraging a continuous improvement mindset.
   • Participatory Continuation: We might recommend continuing the participatory approach by forming a working group of ED staff who, informed by this research, continue to monitor and guide improvement – essentially sustaining an action research ethos beyond the PhD.
   • Implications for Philosophy and Ethics: We’ll also note the consequences for the academic field – e.g., demonstrating the value of pragmatism as a guiding framework for clinical ethics interventions or showing how Stoic ethics can be practically applied in modern healthcare contexts to improve clinician well-being and patient care. We may call for more “field philosophy” in acute care settings.
   • Future Research: Identify open questions, for example, evaluating the outcomes of implementing these recommendations (does patient/family satisfaction improve? Do ED staff experience less moral distress? Does it reduce unnecessary admissions?). Or expanding research to patient perspectives – our study focuses on clinicians. Still, an essential next step is to understand how patients and their families perceive these ED conversations, or the lack thereof, to capture the picture fully. Also, investigating how findings might translate to other contexts (like ICU or other countries’ ED systems) could be mentioned.

Finally, we will conclude with a strong closing that ties back to the bigger vision: an ED that is not only a place of life-saving critical care but also a place of humane, values-aligned decision-making for all patients. We’ll emphasise how the PhD has contributed to that vision by illuminating the interplay of culture and ethics in the ED and by proposing a path forward grounded in both practical reality and philosophical wisdom.

Throughout the thesis, citations to evidence and sources will be meticulously provided, following the required format. This includes citing our connected sources and relevant literature to lend weight to our analysis (for example, using the data from Argintaru et al. 2019 or Lamba et al. 2013, as we have in this proposal).

The writing will aim to be clear and accessible not only to academic supervisors but also to interdisciplinary readers – we anticipate examiners or stakeholders from both medical and ethics backgrounds. Thus, we will define terms clearly and ensure the narrative is engaging, with real examples that illustrate key points (much as we used a narrative in this proposal about the intubation scenario to ground the discussion).

By following this structure, the thesis will logically flow from context to theory, to method, to results, to analysis, and solutions. Each part builds on the previous, culminating in a coherent argument that answers our research questions and achieves our aim of an empirically informed, philosophically rich understanding of ED decision-making culture.

Conclusion and Practical Significance

In closing, this PhD project will produce a detailed, PhD-level analysis that is both intellectually rigorous and pragmatically useful. By examining how ED culture and team dynamics influence the initiation of conversations before investigations, we aim to uncover the hidden assumptions and pressures that currently hinder patient-centred decision-making. Moreover, by leveraging the insights of pragmatism and stoicism, we will not only diagnose the problem but also articulate a vision for better practice: one where emergency clinicians can balance swift action with thoughtful pause, where seeking input on a patient’s values is seen as part of excellent emergency care, not an optional add-on.

The practical implications are substantial. Findings from this study can inform hospital policies – for example, encouraging early goals-of-care clarification for high-risk patients in ED (which could reduce unwanted invasive care and downstream costs). They can inform training curricula for emergency medicine: our data-backed recommendations may encourage the inclusion of mandatory communication training or rotations with palliative care for residents. At a cultural level, disseminating this work can spark conversation among ED professionals, potentially contributing to a culture shift that values “the conversation” as much as “the intervention.” This aligns with broader healthcare quality trends that emphasise patient-centred care and shared decision-making, even in acute settings.

Furthermore, incorporating the CAREPACT experience ensures that the research remains anchored in practical leadership insights – demonstrating how change can be implemented (and the obstacles it faces). CAREPACT’s success in improving aged care pathways exemplifies the kind of outcome this research ultimately strives for: systems where frail older adults receive care aligned with their needs and preferences, avoiding the harms of both under and over-treatment.

In essence, this project is an opportunity to bring the “humanities” into the hurly-burly of the emergency department, using philosophy not as an abstract theory but as a tool to make sense of and improve clinical practice. It sits at the intersection of ethics, communication, and health services research, precisely where health humanities and the philosophy of medicine can have the most significant impact. By the end of this work, we anticipate providing:

• A set of key research questions was answered (with a nuanced understanding of ED cultural factors and their effects on behaviour).
• A model or framework for thinking about ED decision-making under uncertainty (potentially publishable as a conceptual piece, integrating our pragmatic-stoic analysis).
• Empirical findings can be published in medical journals (e.g. a qualitative study on ED clinicians’ perspectives, which could help inform policy-makers and ED directors).
• Actionable guidance for ED teams and hospital administrators seeking to improve the care of older patients (possibly distilled into an executive summary or toolkit as an output).
• Academically, it demonstrates how bridging disciplines yields deeper insights – something future scholars can build upon in other contexts (e.g., applying similar approaches to ICU or ambulance services).

Ultimately, the measure of success for this PhD will be twofold: (1) contributing original knowledge to scholarship (by filling the gap around ED cultural analysis and introducing a novel philosophical integration), and (2) providing a foundation for real-world improvements in emergency care practices and clinician education. By favouring an empirical trajectory enriched with theory, this project maximises its relevance and depth. It upholds the pragmatic philosophy it espouses – valuing ideas by their practical bearings – and aspires to exemplify the stoic virtues of wisdom and courage in its examination of one of the most challenging arenas of medicine.

In the words of one ED physician reflecting on changing practice, “It takes courage to pause”. This research seeks to foster that courage in emergency clinicians by changing the environment and culture around them. In doing so, it will help emergency medicine live up to its fullest promise: not only to save lives in the immediate sense but to ensure that the care delivered in those critical moments is the right care for each individual – even, and especially when that means having a compassionate conversation instead of a test.

References

1.           Argintaru N, Quinn KL, Chartier LB, Lee J, Hannam P, O’Connor E, et al. Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents. Canadian Journal of Emergency Medicine [Internet]. 2019 Mar 1 [cited 2025 Jun 7];21(2):211–8. Available from: https://pubmed.ncbi.nlm.nih.gov/29737962/

2.           Adeyemi O, Ginsburg AD, Kaur R, Cuthel A, Zhao N, Siman N, et al. Serious Illness Communication Skills Training for Emergency Physicians and Advanced Practice Providers: A Multi-Method Assessment of the Reach and Effectiveness of the Intervention. Res Sq [Internet]. 2023 Feb 21 [cited 2025 Jun 7];rs.3.rs-2561749. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9980220/

3.           Miller DG. Barriers to Palliative Care in the Emergency Department (ED)—Results from a National Survey of Emergency Physicians (Sch413). J Pain Symptom Manage [Internet]. 2023 May 1 [cited 2025 Jun 7];65(5):e585–6. Available from: https://www.jpsmjournal.com/action/showFullText?pii=S0885392423002294

4.           Grudzen CR, Emlet LL, Kuntz J, Shreves A, Zimny E, Gang M, et al. EM Talk: communication skills training for emergency medicine patients with serious illness. BMJ Support Palliat Care [Internet]. 2016 Jun 1 [cited 2025 Jun 7];6(2):219–24. Available from: https://spcare.bmj.com/content/6/2/219

5.           Cameron B, Laupacis A. Where do goals of care conversations belong? A case for the emergency department. Canadian Journal of Emergency Medicine [Internet]. 2019 Nov 1 [cited 2025 Jun 7];21(6):698–700. Available from: https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/where-do-goals-of-care-conversations-belong-a-case-for-the-emergency-department/943265E066DD7B63CCBF420C2B7DB761

6.           Ouchi K, Wu M, Medairos R, Grudzen CR, Balsells H, Marcus D, et al. Initiating palliative care consults for advanced dementia patients in the emergency department. J Palliat Med [Internet]. 2014 Mar 1 [cited 2025 Jun 7];17(3):346–50. Available from: https://pubmed.ncbi.nlm.nih.gov/24387752/

7.           Carpenter CR, Dresden SM, Shah MN, Hwang U. Adapting Emergency Care for Persons Living With Dementia: Results of the Geriatric Emergency Care Applied Research Network Scoping Review and Consensus Conference. J Am Med Dir Assoc [Internet]. 2022 Aug 1 [cited 2025 Jun 7];23(8):1286–7. Available from: https://pubmed.ncbi.nlm.nih.gov/35940679/

8.           Burkett E, Scott I. CARE-PACT: a new paradigm of care for acutely unwell residents in aged care facilities. Aust Fam Physician. 2015 Apr;44(4):204–9. 

9.           Dewey J. The Quest for Certainty: A Study of the Relation of Knowledge and Action [Internet]. Minton, Balch; 1929 [cited 2025 Jun 7]. Available from: https://psycnet.apa.org/record/1930-00008-000

10.        Stoicism (Stanford Encyclopedia of Philosophy) [Internet]. [cited 2025 Jun 7]. Available from: https://plato.stanford.edu/entries/stoicism/