ObjectiveTo examine secondary care consultant clinicians’ experiences of conducting conversations about treatment escalation with patients and their relatives, using the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process.DesignSemi-structured interviews following ward round observations.SettingTwo National Health Service hospitals in England.ParticipantsFifteen medical and surgical consultants from 10 specialties, observed in 14 wards.AnalysisInterview transcripts were analysed using thematic analysis.ResultsThree themes were developed: (1) determining when and with whom to conduct a ReSPECT conversation; (2) framing the ReSPECT conversation to manage emotions and relationships and (3) reaching ReSPECT decisions. The results showed that when timing ReSPECT conversations, consultant clinicians rely on their predictions of a patient’s short-term prognosis; when framing ReSPECT conversations, consultant clinicians seek to minimise distress and maximise rapport and when involving a patient or a patient’s relatives in decision-making discussions, consultant clinicians are guided by their level of certainty about the patient’s illness trajectory.ConclusionsThe management of uncertainty about prognoses and about patients’ emotional reactions is central to secondary care consultant clinicians’ experiences of timing and conducting ReSPECT conversations.