Beyond Protocol Working – a review of clinical decision making for older patients presenting with suspected pneumonia

Problem

Community Acquired Pneumonia (CAP) is a common presentation in acute healthcare settings. Established guidelines describe management; however, for many older multi-morbid patients, single-disease-focused guidelines may not be applicable. Clinicians need to use alternative strategies in these ‘beyond-protocol’ situations. This review has determined the factors influencing decision making whilst working outside guideline-defined care.

Approach

Systematic database search (Cinahl, Embase, Ovid Medline and PsycINFO) identified 367 published articles about older (>60), co-morbid patients, with a diagnosis of CAP, Lower Respiratory Tract Infection or Aspiration Pneumonia. Abstract screening identified 64 papers for full text review and 44 articles were included in this scoping review. Narrative review, involving thematic analysis, using a priori themes applied to the first ten papers, developed a coding framework. Two coding concepts were identified: the type of clinical decision and key factors influencing it. This framework was used to extract data from all included studies, and the EPPI assessment tool was applied to assess rigor.

Findings

Three broad types of decision-making for older patients with pneumonia were noted; whether to treat, the location of treatment and clinicians’ adherence to guidelines. The key factors influencing these decisions were; the patient, the disease, the clinician, the health system, and the interaction between clinician and patient, relative or carer. Five main analytic themes were identified; Assessment of Pneumonia Severity, Vulnerability to Pneumonia, Patient and Family wishes for treatment, Clinical Reasoning and Judgement and Use of Guidelines.

Guidelines were often studied to measure the effect of changing the doctor’s behaviour on patient outcome. The most common reasons to override clinical guidelines for pneumonia in older people was the presence of co-morbidities, severity of disease, including hypoxia, and social factors. These factors were felt to increase patient’s vulnerability to disease and often lead to hospitalisation. Few studies discussed patient preferences, but when investigated preferences could change depending on the information provided. There was a lack of discussion of the clinician factors that affect decision making including communication between the patient and clinician.

Consequences

The current literature focused on the application of guidelines, but often concluded that clinician judgement should be used to make individualised clinical decisions. We demonstrate a gap in the knowledge about how clinician factors affect decision-making, including best practice when communicating between the patient and clinician in the acute treatment of respiratory infection. Further research is needed to develop a taxonomy of “clinically appropriate overrides” (Halm 2000) to help clinicians have a language to justify their reasoning and to promote an individually tailored approach to patient care.