PONE-D-19-20806

De-coding the language; how clinicians interpret resuscitation clinical care plans. A mixed methods study

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Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: This is an interesting study that I believe would be of interest to the international community involved in developing and implementing the use of emergency care and treatment plans.

Whilst the paper has been presented well, I believe that some revision would improve it and increase its value to readers.

I feel that the title of the paper (in particular the use of the word ‘de-coding’) does not reflect the study’s findings and paper’s content accurately in a way that will help readers to find it and know what it is about. The main message from the findings of this study is that use of ambiguous language in resuscitation plans – unsurprisingly – results in different interpretation among doctors and in different decisions about choices of emergency treatments. I suggest that the title is amended to reflect this clearly.

The text states that 3 of the 4 authors ‘contributed equally to this work’. The nature and extent of their equal contributions are not stated. I suggest that this be corrected.

There is a degree of irony in this paper that addresses ambiguity and misinterpretation of terminology within a document that itself has the ambiguous name ‘resuscitation plan’. Some people use or interpret ‘resuscitation’ as referring to cardiopulmonary resuscitation, whereas others will use terminology such as ‘fluid resuscitation’ and some consider other emergency treatments as being part of ‘resuscitation’. The study identifies that doctors have different perceptions of the purpose and value of a ‘resuscitation plan’. The paper could usefully discuss whether that might be resolved, at least in part, by using a different, more specific name for the plan and/or a clear statement on the form of its purpose.

A weakness of this study, which should be acknowledged in the text, is that it has asked doctors to interpret (in the context of case vignettes) free-text phrases used on resuscitation plans from 2017 that were examined in a previous study. That previous study concluded that these phrases were ‘open to broad, variable interpretation’ and that ‘…ongoing education is integral to changing practice’. The present study has – unsurprisingly – validated the first of these conclusions, and – disappointingly – the current paper fails to acknowledge the crucial role of education (including audit, appraisal and feedback) in persuading doctors to record clear recommendations and stop using ambiguous phrases. If these phrases are in widespread use, that appears to indicate failure of adequate staff education in the completion of the 7-step form.

In more than one place, the text states ‘Terminology was neither consistently interpreted nor applied…’. I think that the authors intended to state that terminology was neither interpreted consistently nor applied consistently, not that the ‘terminology’ was not applied.

The paper refers to ‘not for Cardiopulmonary Resuscitation orders’ but does not make clear the legal status of such documents in Australia. In the UK, such documents are not legally binding ‘orders’ but are recommendations to guide those dealing with a sudden emergency to make the best possible decisions about the emergency care and treatment of the person, when the person has lost capacity to make choices about their care and treatment. The legal status of similar documents varies from country to country, so I think – especially in an international journal – that this should be acknowledged and discussed in this paper.

The paper states that the 7-step form is being used in all ‘public tertiary hospitals’ in South Australia. This terminology is potentially ambiguous for an international readership, so it would be helpful for the text to define the type, size and number of hospitals covered by this term.

It would be helpful and of great interest also to understand what arrangements are in place to communicate recommendations for the emergency care and treatment of patients who have not been admitted to this type of hospital, or patients transferred or discharged from a tertiary hospital. For the provision of person-centred care, I think there should be a robust process to transfer an up-to-date and relevant 7-step form with the patient or to generate current recommendations for emergency care and treatment on a different document. Whichever document is used outside the tertiary hospitals must be widely used, recognised and accepted across a range of other care settings, by a broad range of health and care professionals. Clearly, the ambiguous terminology used in this study to explore interpretation by hospital doctors would be likely to be even more ambiguous to health and care professionals if used on a form held by a patient at home or in various other care settings.

The paper implies in a single sentence that the 7-step form is very similar to 'international counterparts'. This is not strictly true. There are substantial differences, and it would be appropriate to identify these in the text and to consider them in subsequent discussion of possible options for improving the design of the 7-step form to overcome the problems identified in this study.

There is published evidence that using a discussion process and form that focus on and record treatments that would be wanted and should be considered to help to achieve the person’s goals of care, not primarily on treatment to be withheld, are preferred by both patients and by healthcare professionals. The ‘7-step form’ appears to focus more on withholding treatment rather than on giving realistic care and treatment to meet the person’s goals of care. As such, it does not appear truly person-centred or evidence-based.

In the published report of their previous study (reference 4) the authors concluded that the current Alert Form (‘7-step form’) could be improved. The tick-box list in section 4 of the form focuses firstly on emergency treatments to be withheld, emphasised using red print. Treatments that ‘will be provided’ are relegated to a rather less prominent free-text box below. Even the wording in this box is ambiguous. This box should list treatments that would be wanted and should be considered – and provided if they are needed. I would like to see much more discussion about the substantial potential to improve the form and to try to ensure that the form is used to support good communication, good medical practice and person-centred care, rather than primarily supporting the healthcare system.

In the discussion section, the paper suggests ‘To further improve clarity for junior staff, free-text options could be replaced with standardised choices e.g. non-invasive ventilation, cardiac monitoring, artificial hydration and intravenous antibiotics’. I am concerned that this would be primarily a system-focused intervention that is not truly person-centred. There are several potential ways in which the form could be modified to make it more person-centred and less likely to lead to varying interpretation and incorrect decision making in an emergency, and I would like to see the discussion expanded to consider these other options and the advantages and disadvantages of each. Trying to create a comprehensive list of tick-box treatment options to cater for every person's individual needs seems likely to make the form unduly long and cumbersome for all, and trying to limit the number of treatment options will inevitably fail to cater for all individual needs.

I am sorry to raise so many suggestions and hope that they will be viewed in the constructive spirit intended, and used to develop this interesting paper to its full potential.

Reviewer #2: I think you did a good job with a difficult research topic. I added a couple of comments about discussing the vignette management differences seen. I thought you addressed the language ambiguity in the second part well.

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Reviewer #1: Yes: Dr David Pitcher

Reviewer #2: Yes: Michael Ritchie

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Submitted filename: PONE-D-19-20806_reviewer.docx

The impact of language on the interpretation of resuscitation clinical care plans by doctors. A mixed methods study

PONE-D-19-20806R1

Dear Dr. Dignam,

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