Emergency Department Dispositions for People With Dementia: Perspectives From Patients, Care Partners, and Health Care Professionals

ED disposition decisions for people living with dementia (PLWD) are complex and uncertain, and care partner (CP) engagement is inconsistently applied. Perspectives from lived experiences are needed to understand factors shaping these conversations. This study aimed to identify factors influencing disposition preferences among PLWD, CP, and health care professionals (HCP), and to characterize approaches to decision-making conversations.

Qualitative study using semi-structured interviews with PLWD and CP after an ED visit at a single VA medical center, and HCP at two VA medical centers. Separate interview guides were developed for patients, CP, and HCP, based on decisional needs in the Ottawa Decision Support Framework. PLWD were eligible for interviews if they demonstrated capacity to consent using a validated tool. Interviews were conducted by telephone and professionally transcribed. Data were analyzed in NVivo by three analysts using an inductive thematic approach to collaboratively develop codebooks and identify emerging themes. To enhance rigor, discrepancies were resolved through consensus.

Interviews were conducted from February to September 2025. The sample included 30 Veterans and CP dyads (n=60), and 15 HCP (10 physicians, 3 social workers, 2 utilization nurses). PLWD mean age was 82.8 [SD 7.4]; 97% male; 57% Black; dementia severity was mild in 12 (40%), moderate in 9 (30%), and severe in 9 (30%). Ten PLWD participated in interviews. CP mean age was 65.4 [SD 13.3]; 93% female; 54% Black. Major themes included: 1. PLWD, CP, and HCP differed in how they weighed factors when forming disposition preferences. PLWD emphasized comfort at home versus the hospital, CP focused on return to baseline and available support, and HCP focused on new clinical changes and home safety. 2. PLWD factors like capacity, autonomy, and safety were critical to participation and shaped preferences. 3. Approaches to managing discrepant preferences varied, as did preferred decisional roles among the groups.

ED disposition decision-making is highly individualized. Providers play a critical role in guiding discussions, particularly when PLWD and CP preferences diverge, and their approach may be informed by each party’s preferred decisional role. Findings can inform the development of a communication tool to facilitate such conversations.