Resuscitation preference conversation typologies: a constructivist grounded theory study.

PURPOSE: Despite considerable effort, concerns over the quality of the outcomes of resuscitation preference conversations continue. In part, the problem relates to inadequate attention to conversation complexity and the development of oversimplified guides. We aimed to develop a more nuanced understanding of the complexity of real-world resuscitation preference conversations that examines the multiple challenges encountered. METHODS: We used Charmazian-constructivist grounded theory to analyze 106 clinical notes from a data set of 366 detail-rich resuscitation preference conversation narratives. Sampling was purposive and focused on maximum variation. Rigor was enhanced through iterative data collection and analysis and constant comparison. RESULTS: All conversations could be described as one of five typologies (standard or middle ground, fighter, conflict or conflicted, avoidance or deferral, and wrong conversation) and two modifiers (re-exploration and health care team concerns about preference) that provide insights into the patients' rationale for decision-making. We also identified 28 conversation foci, which appeared necessary to address, when present, to continue with the conversations (e.g., denial or family conflict). Conversations also benefited from the expression of health care team concern with choice, when needed. Addressing what-if and what-next provided additional nuance on how to proceed postresuscitation, especially for challenging conversations. CONCLUSIONS: The strategy of structuring and engaging with various conversation foci and typologies as they arise, and the importance of exploring what-if and what-next are important additions to the literature and existing guides. Our findings add to existing resources in ways that can hopefully be used to improve clinical practice and training.