Table 2 “Examples of the data analysis”

The older woman (in trajectory 1) asks for water in a sip-cup after transferred to the geriatric department. Her wish is expressed more than once but overruled by a nursing practice to prevent swallow failure and pneumonia risk

The woman used a sip-cup at the ED. In the geriatric department her wish is ignored. She is offered a straw instead to prevent swallow failure. Practice seems conflicting with patient needs or wishes.

Conflict between practice and patients’ needs

Due to a hemiparesis, the older woman uses a sip cup (with a spouted lid) to drink without assistance. Despite asking for a sip cup at the geriatric department, the nurse comes with a regular drinking glass. The nurse explains that drinking from a sip cup can contribute to failure to swallow correctly, increasing the risk of pneumonia. To compromise, the nurse brings the older woman a straw to use. However, this is also impossible for the woman to use.

The end justifies the means – “I know what is best for you”

The older woman (in trajectory 5) was admitted after several days of severe vomiting and diarrhea. She has not been eating or drinking sufficiently for days. Two small juice boxes has been placed besides her, but she is not able to drink due to the straight straw. She was neither offered lunch.

I wonder what role basic care has in the older woman’s CCT, and if basic motivation to eat and drink and better preconditions (As e.g. an appropriate straw) would have benefited the woman’s CCT

Basic care needs

I ask if she would like something to drink.

She says, “Yes, but the apple juice is empty, and I don’t like orange juice”.

As I lift the apple juice, I realize that it is half-full, but due to the straight straw, impossible for her to drink, giving the impression that it is empty. After locating a bendable straw, she can drink by herself. As she has not eaten any lunch and it’s past noon, I ask her, if she has ordered anything.

“No”, she says, “I don’t feel like eating anything”.

“Well, what about a small soup then”, I suggest.

“Well, I think I can eat that”, the older woman replies.

Basic needs of care overruled by system effectiveness

There are different perceptions of, what the older person (in Trajectory 2) suffers and what treatment is most appropriate. The physicians argue whether or not he is a cardiac patient.

Organisational structures and power clashes between professions and entities affect the care planning in the CCTs

Care coordination across settings

Later, the nurse calls the medical department to arrange the transfer to continue treatment for heart failure. The nurse at the medical department says to the ED nurse that she will try to arrange a ‘trade’ by moving one patient from the cardiology department to the medical department, to be able to transfer the older person directly to the cardiology department. After hanging up the phone, the nurse turns to me and says: “Well, now my patient is involved as a bargaining chip to receive the best treatment.

Treatment as a bargain

The older person (in Trajectory 3) is admitted by his GP for thorough investigation after fall episodes in the home and general declining level of function. The GP is familiar with his use of alcohol.

People who are not able to be proper carriers of information’ is a challenge for the care coordination, responsibility is mis-placed unintendedly with the pt.

Abrupted care distorted by the pt’s/person’s perspectives

During the person’s hospital stay, he is examined by several physicians to find an explanation for his fall episodes. Every time he is approached by a medical professional, he has an alternative explanation or reveals a new place of pain or raises an additional problem. This results in, every physician having a new focus for treatment.

Healthcare professionals as solo-detectives