Shared Decision Making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement

Implementation of a Bundled Consent Process in the ICU: A Single-Center Experience

OBJECTIVES

A bundled consent process, where patients or surrogates provide consent for all commonly performed procedures on a single form at the time of ICU admission, has been advocated as a method for improving both rates of documented consent and patient/family satisfaction, but there has been little published literature about the use of bundled consent. We sought to determine how residents in an academic medical center with a required bundled consent process actually obtain consent and how they perceive the overall value, efficacy, and effects on families of this approach.

DESIGN

Single-center survey study.

SETTING

Medical ICUs in an urban academic medical center.

SUBJECTS

Internal medicine residents.

INTERVENTIONS

We administered an online survey about bundled consent use to all residents. Quantitative and qualitative data were analyzed.

MEASUREMENTS AND MAIN RESULTS

One-hundred two of 164 internal medicine residents (62%) completed the survey. A majority of residents (55%) reported grouping procedures and discussing general risks and benefits; 11% reported conducting a complete informed consent discussion for each procedure. Respondents were divided in their perception of the value of bundled consent, but most (78%) felt it scared or stressed families. A minority (26%) felt confident that they obtained valid informed consent for critical care procedures with the use of bundled consent. An additional theme that emerged from qualitative data was concern regarding the validity of anticipatory consent.

CONCLUSIONS

Resident physicians experienced with the use of bundled consent in the ICU held variable perceptions of its value but raised concerns about the effect on families and the validity of consent obtained with this strategy. Further studies are necessary to further explore what constitutes best practice for informed consent in critical care.

Interprofessional Shared Decision-Making in the ICU: A Systematic Review and Recommendations From an Expert Panel

OBJECTIVES

There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation.

DATA SOURCES

We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making.

STUDY SELECTION

Three authors screened titles and abstracts in duplicate.

DATA SYNTHESIS

Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs.

CONCLUSIONS

Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.

Negotiating the 'buffet' of choice: advances in technology and end-of-life decision-making in the intensive care unit setting

In recent years, increases in medical technologies in the critical care setting have advanced the practice of medicine, enabling patients to live longer while also creating dilemmas for end-of-life decision-making. Clinicians have increasingly been called on to involve patients and family members in decision-making through a process of shared decision-making (SDM), yet less is known about how SDM plays out in the critical care setting and the ways in which clinicians engage in SDM. Using observational data from 14 months of ethnographic fieldwork in two intensive care units and interviews with 33 family members of 25 critically ill patients and 51 clinicians, I explore how clinicians refer to the choices available in medical decision-making paradoxically as a 'buffet' of choice while they simultaneously recognise that such rhetoric is misaligned with complex and emotional decision-making, often involving pain and suffering. Lastly, this paper considers the role of SDM and the ways in which clinicians push back on the 'buffet' rhetoric and engage in practices to guide families in end-of-life decision-making by granting permission for families to make decisions and validating their decisions to decline treatment when there is an opportunity for more treatment.

Physician Self-assessment of Shared Decision-making in Simulated Intensive Care Unit Family Meetings

IMPORTANCE

Professional guidelines have identified key communication skills for shared decision-making for critically ill patients, but it is unclear how intensivists interpret and implement them.

OBJECTIVE

To compare the self-evaluations of intensivists reviewing transcripts of their own simulated intensive care unit family meetings with the evaluations of trained expert colleagues.

DESIGN, SETTING, AND PARTICIPANTS

A posttrial web-based survey of intensivists was conducted between January and March 2019. Intensivists reviewed transcripts of simulated intensive care unit family meetings in which they participated in a previous trial from October 2016 to November 2017. In the follow-up survey, participants identified if and how they performed key elements of shared decision-making for an intensive care unit patient at high risk of death. Transcript texts that intensivists self-identified as examples of key communication skills recommended by their professional society's policy on shared decision-making were categorized.

MAIN OUTCOMES AND MEASURES

Comparison of the evaluations of 2 blinded nonparticipant intensivist colleagues with the self-reported responses of the intensivists.

RESULTS

Of 116 eligible intensivists, 76 (66%) completed the follow-up survey (mean [SD] respondent age was 43.1 [8.1] years; 72% were male). Sixty-one of 76 intensivists reported conveying prognosis; however, blinded colleagues who reviewed the deidentified transcripts were less likely to report that prognosis had been conveyed than intensivists reviewing their own transcripts (42 of 61; odds ratio, 0.10; 95% CI, 0.01-0.44; P < .001). When reviewing their own transcript, intensivists reported presenting many choices, with the most common choice being code status. They also provided a variety of recommendations, with the most common being to continue the current treatment plan. Thirty-three participants (43%) reported that they offered care focused on comfort, but blinded colleagues rated only 1 (4%) as explaining this option in a clear manner.

CONCLUSIONS AND RELEVANCE

In this study, guidelines for shared decision-making and end of life care were interpreted by intensivists in disparate ways. In the absence of training or personalized feedback, self-assessment of communication skills may not be interpreted consistently.

End-of-life practices in traumatic brain injury patients: Report of a questionnaire from the CENTER-TBI study

PURPOSE

We aimed to study variation regarding specific end-of-life (EoL) practices in the intensive care unit (ICU) in traumatic brain injury (TBI) patients.

MATERIALS AND METHODS

Respondents from 67 hospitals participating in The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study completed several questionnaires on management of TBI patients.

RESULTS

In 60% of the centers, ≤50% of all patients with severe neurological damage dying in the ICU, die after withdrawal of life-sustaining measures (LSM). The decision to withhold/withdraw LSM was made following multidisciplinary consensus in every center. Legal representatives/relatives played a role in the decision-making process in 81% of the centers. In 82% of the centers, age played a role in the decision to withhold/withdraw LSM. Furthermore, palliative therapy was initiated in 79% of the centers after the decision to withdraw LSM was made. Last, withholding/withdrawing LSM was, generally, more often considered after more time had passed, in a patient with TBI, who remained in a very poor prognostic condition.

CONCLUSION

We found variation regarding EoL practices in TBI patients. These results provide insight into variability regarding important issues pertaining to EoL practices in TBI, which can be useful to stimulate discussions on EoL practices, comparative effectiveness research, and, ultimately, development of recommendations.

Persistence of patient and family experiences of critical illness

OBJECTIVE

To investigate: (1) patient and family experiences with healthcare and the intensive care unit (ICU); (2) experiences during their critical illness; (3) communication and decision making during critical illness; (4) feelings about the ICU experience; (5) impact of the critical illness on their lives; and (6) concerns about their future after the ICU.

DESIGN

Four semistructured focus group interviews with former ICU patients and family members.

SETTINGS

Multicultural community group and local hospitals containing medical/surgical ICUs.

PARTICIPANTS

Patients and family who experienced a critical illness within the previous 10 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four separate focus groups each lasting a maximum of 150 min and consisting of a total of 21 participants were held. Focus groups were conducted using a semistructured script including six topics relating to the experience of critical illness that facilitated deduction and the sorting of data by thematic analysis into five predominant themes. The five main themes that emerged from the data were: (1) personalised stories of the critical illness; (2) communication and shared decision making, (3) adjustment to life after critical illness, (4) trust towards clinical team and relevance of cultural beliefs and (5) end-of-life decision making. Across themes, we observed a misalignment between the medical system and patient and family values and priorities.

CONCLUSIONS

The experience of critical illness of a diverse group of patients and families can remain vivid for years after ICU discharge. The identified themes reflect the strength of memory of such pivotal experiences and the importance of a narrative around those experiences. Clinicians need to be aware of the lasting effects of critical illness has on patients and families.

Overview of the main challenges in shared decision making in a multicultural and diverse society in the intensive and critical care setting

BACKGROUND

In shared decision making, health care professionals and patients collaborate in making health-related choices. This process is based on autonomy and constitutes one to the elements of patient-centered care. However, there are situations where shared decision making is more difficult, if not impossible, due to barriers, which may be related to language, culture, education, or mental capacity and external factors like the state of emergency or the availability of alternative sources of information.

AIM

The aim of this paper is to identify some of the main obstacles to the adoption of shared decision making in an intensive and critical care scenario and discuss potential ways to facilitate its implementation.

METHODS

We conducted a literature review on shared decision making from the perspective of intensive and critical care specialists.

DISCUSSION

Although the health care context is complex and the variety of situation that can arise makes it impossible to prepare professionals for every occurrence, shared decision making process should be structured at an organization level, engaging health care professionals, experts of communication, and patient representatives coming from different cultural backgrounds, languages, and education to assemble for all the main procedures, where shared decision making is involved, the specific information packages health care professionals will use in order to guide them through the process and ensuring all patients receive a comparable level of engagement. Shared decision making should not become a hindrance for the health care professional but on the contrary a way to strengthen their relationship with the patient.

CONCLUSION

The implementation of the shared decision making approach at an organization-wide level improves its quality and effectiveness.

Historical Perspectives: Shared Decision Making in the NICU

The ethical dilemmas and predominant frameworks surrounding decision making for critically ill newborns have evolved substantially over the last 40 years. A shared decision-making approach is now favored, involving an exchange of information between parents and clinicians that emphasizes parental values and preferences, resulting in a personalized approach to decision making. In this review, we summarize the history of clinical decision making with a focus on the NICU, highlight different models of decision making, describe the advantages and current limitations of shared decision making, and discuss the ongoing and future challenges of decision making in the NICU amidst medical innovations and emerging technologies.

Meaningful shared decision-making: complex process demanding cognitive and emotional skills

BACKGROUND

Shared decision-making (SDM) takes place when clinicians help patient identify best course of action in the context of their preferences.

METHODS

The aim of this paper is a narrative review of the literature with special focus on the humanistic dimensions of SDM.

RESULTS

We show that SDM is largely underused in practice, because of many barriers such as time constraints and poor skills.

CONCLUSIONS

We suggest that listening and empathy are key challenges in communicating uncertainty, which require emotional intelligence and trust building skills. To promote implementation, we propose the development of tools, simulation-based training and the design of improved measures for SDM quality. While essential for patients, we believe that SDM may restore meaning in healthcare.

Survival, Outcomes, and Use of Acuity Scoring Systems Following Tracheotomy in Veteran Patients

OBJECTIVES

To determine whether established prognosis tools used in the general population of critically ill patients will accurately predict tracheotomy-related outcomes and survival outcomes in critically ill patients undergoing tracheotomy.

METHODS

Retrospective chart review of 94 consecutive critically ill patients undergoing isolated tracheotomy.

RESULTS

Logistic Organ Dysfunction System (LODS) and sepsis-related organ failure assessment (SOFA) scores, 2 validated measures of acuity in critically ill patients, were calculated for all patients. The only tracheotomy-related outcome of significance was the finding that patients with an LODS score ≤6 were more likely to become ventilator independent (P < .015). Higher LODS or SOFA scores were associated with in-house death (LODS, P = .001, SOFA, P = .008) and death within 90 days (LODS, P = .009, SOFA, P = .031), while death within 180 days was associated only with a higher LODS score (LODS, P = .018). When controlling for age, there was an association between both LODS (P = .015) and SOFA (P = .019) scores and death within 90 days of tracheotomy.

CONCLUSIONS

The survival outcome for critically ill patients undergoing tracheotomy seems accurately predicted based on scoring systems designed for use in the general population of critically ill patients. Logistic Organ Dysfunction System may also be useful to predict the likelihood of the tracheotomy-related outcome of ventilator independence. This suggests that LODS scores may be helpful to palliative care clinicians as part of a shared decision-making aid in critically ill, ventilated patients for whom tracheotomy is being considered.

Protocol for a randomised trial of an interprofessional team-delivered intervention to support surrogate decision-makers in ICUs

INTRODUCTION

Although shortcomings in clinician-family communication and decision making for incapacitated, critically ill patients are common, there are few rigorously tested interventions to improve outcomes. In this manuscript, we present our methodology for the Pairing Re-engineered Intensive Care Unit Teams with Nurse-Driven Emotional support and Relationship Building (PARTNER 2) trial, and discuss design challenges and their resolution.

METHODS AND ANALYSIS

This is a pragmatic, stepped-wedge, cluster randomised controlled trial comparing the PARTNER 2 intervention to usual care among 690 incapacitated, critically ill patients and their surrogates in five ICUs in Pennsylvania. Eligible subjects will include critically ill patients at high risk of death and/or severe long-term functional impairment, their main surrogate decision-maker and their clinicians. The PARTNER intervention is delivered by the interprofessional ICU team and overseen by 4-6 nurses from each ICU. It involves: (1) advanced communication skills training for nurses to deliver support to surrogates throughout the ICU stay; (2) deploying a structured family support pathway; (3) enacting strategies to foster collaboration between ICU and palliative care services and (4) providing intensive implementation support to each ICU to incorporate the family support pathway into clinicians' workflow. The primary outcome is surrogates' ratings of the quality of communication during the ICU stay as assessed by telephone at 6-month follow-up. Prespecified secondary outcomes include surrogates' scores on the Hospital Anxiety and Depression Scale, the Impact of Event Scale, the modified Patient Perception of Patient Centredness scale, the Decision Regret Scale, nurses' scores on the Maslach Burnout Inventory, and length of stay during and costs of the index hospitalisation.We also discuss key methodological challenges, including determining the optimal level of randomisation, using existing staff to deploy the intervention and maximising long-term follow-up of participants.

ETHICS AND DISSEMINATION

We obtained ethics approval through the University of Pittsburgh, Human Research Protection Office. The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02445937.

Patient and Family Engagement During Treatment Decisions in an ICU: A Discourse Analysis of the Electronic Health Record

OBJECTIVES

Shared decision-making is recommended for critically ill adults who face major, preference-sensitive treatment decisions. Yet, little is known about when and how patients and families are engaged in treatment decision-making over the longitudinal course of a critical illness. We sought to characterize patterns of treatment decision-making by evaluating clinician discourse in the electronic health record of critically ill adults who develop chronic critical illness or die in an ICU.

DESIGN, SETTING, AND PATIENTS

We conducted qualitative content analysis of the electronic health record of 52 adult patients, admitted to a medical ICU in a tertiary medical center from January 1, 2016, to December 31, 2016. We included patients who met a consensus definition of chronic critical illness (26 patients) and a matched sample who died or transitioned to hospice care in the ICU before developing chronic critical illness (26 patients).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Characterization of clinician decision-making discourse documented during the course of an ICU stay. Clinician decision-making discourse in the electronic health record followed a single, consistent pattern across both groups. Initial decisions about admission to the ICU focused on specific interventions that can only be provided in an ICU environment (intervention-focused decisions). Following admission, the documented rationale for additional treatments was guided by physiologic abnormalities (physiology-centered decisions). Clinician discourse transitioned to documented engagement of patients and families in decision-making when treatments failed to achieve specified physiologic goals. The phrase "goals of care" is common in the electronic health record and is used to indicate poor prognosis, to describe conflict with families, and to provide rationale for treatment limitations.

CONCLUSIONS

Clinician discourse in the electronic health record reveals that patient physiology strongly guides treatment decision-making throughout the longitudinal course of critical illness. Documentation of patient and family engagement in treatment decision-making is limited until available medical treatments fail to achieve physiologic goals.

Support needs and health-related quality of life of family caregivers of patients requiring prolonged mechanical ventilation and admission to a specialised weaning centre: A qualitative longitudinal interview study

OBJECTIVES

Family caregivers of patients requiring prolonged mechanical ventilation may experience physical and psychological morbidity associated with a protracted intensive care unit experience. Our aim was to explore potentially modifiable support needs and care processes of importance to family caregivers of patients requiring prolonged mechanical ventilation and transition from the intensive care unit to a specialised weaning centre.

RESEARCH METHODOLOGY/DESIGN

A longitudinal qualitative descriptive interview study. Data was analysed using directed content analysis.

SETTING

A 6-bed specialised weaning centre in Toronto, Canada.

FINDINGS

Eighteen family caregivers completed interviews at weaning centre admission (100%), and at two-weeks (40%) and three-months after discharge (22%) contributing 29 interviews. Caregivers were primarily women (61%) and spouses (50%). Caregivers perceived inadequate informational, emotional, training, and appraisal support by health care providers limiting understanding of prolonged ventilation, participation in care and decision-making, and readiness for weaning centre transition. Participants reported long-term physical and psychological health changes including alterations to sleep, energy, nutrition and body weight.

CONCLUSIONS

Deficits in informational, emotional, training, and appraisal support of family caregivers of prolonged mechanical ventilation patients may increase caregiver burden and contribute to poor health outcomes. Strategies for providing support and maintaining family caregiver health-related quality of life are needed.

An acceptability pilot of the facilitating active management in lung illness with engaged surrogates (FAMILIES) study

Approximately half of the surrogate decision makers of critically ill adults are at risk for negative emotional burden. Decision support and effective surrogate-clinician communication buffers against such experiences. The objective of this study is to evaluate the acceptability of a new surrogate-targeted educational tool that promotes engagement with clinicians and advocacy for 2 evidence-based practices in the provision of mechanical ventilation for acute respiratory failure: spontaneous awakening and breathing trials.A panel of 44 former patients and surrogates of a 20-bed medical intensive care unit in a large academic hospital responded to an online survey. Acceptability was measured on 3 dimensions: attitudes toward the content and delivery of information, objective knowledge translation, and subjective knowledge acquisition.More than 80% of participants found the tool to be easy to read, and over 90% felt that the tool provided actionable recommendations. A significant number of previously unsure participants were able to identify what spontaneous awakening and breathing trials are and when they occur, and 16% to 36% reported significant improvements in their subjective understanding of the target evidence-based practices, after being exposed to the educational tool.This line of work seeks to reduce surrogates' negative emotional burden while also promoting quality critical care. The educational tool provides a promising new way to promote surrogate-clinician communication, by increasing surrogates' knowledge about and encouraging advocacy for evidence-based practices in the provision of mechanical ventilation.

On Best Interests: A Case for Clinical Ethics Consultation

Surrogate health care decision making is often a challenge for everyone involved. In the case of incapacitated patients, family members, nurses, health care providers, and other members of the health care team often grapple with determining the most appropriate clinical course of action. For these difficult patient scenarios, the expertise of clinical ethics consultants is sought to assist with complex health care decision making. Clinical ethics consultation is designed to provide a more objective "outside" opinion and offer advice to the patient, family, and entire care team to support and guide decisions. Nurses are well positioned to initiate assistance from Clinical Ethics Consult Services in support of patient and family advocacy. This article presents a case analysis based on the Stakeholder, Facts, Norms, and Options Framework to analyze the best interest course of action for Mr K., a patient diagnosed with abdominal pain due to end-stage liver cirrhosis and who lacks decisional capacity in regard to his own treatment decision making. The case analysis highlights specific examples of how nurses can provide information, facilitate discussion, and otherwise support patients and families to achieve best interest outcomes.

Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association

Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.

What Does the Word "Treatable" Mean? Implications for Communication and Decision-Making in Critical Illness

OBJECTIVES

To explore how nonphysicians and physicians interpret the word "treatable" in the context of critical illness.

DESIGN

Qualitative study using in-depth interviews.

SETTING

One academic medical center.

SUBJECTS

Twenty-four nonphysicians (patients and community members) purposively sampled for variation in demographic characteristics and 24 physicians (attending physicians and trainees) purposively sampled from four specialties (critical care, palliative care, oncology, and surgery).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified two distinct concepts that participants used to interpret the word "treatable": 1) a "good news" concept, in which the word "treatable" conveys a positive message about a patient's future, thereby inspiring hope and encouraging further treatment and 2) an "action-oriented" concept, in which the word "treatable" conveys that physicians have an action or intervention available, but does not necessarily imply an improved prognosis or quality of life. The overwhelming majority of nonphysicians adopted the "good news" concept, whereas physicians almost exclusively adopted the "action-oriented" concept. For some nonphysicians, the word "treatable" conveyed a positive message about prognosis and/or further treatment, even when this contradicted previously stated negative information.

CONCLUSIONS

Physician use of the word "treatable" may lead patients or surrogates to derive unwarranted good news and false encouragement to pursue treatment, even when physicians have explicitly stated information to the contrary. Further work is needed to determine the extent to which the word "treatable" and its cognates contribute to widespread decision-making and communication challenges in critical care, including discordance about prognosis, misconceptions that palliative treatments are curative, and disputes about potentially inappropriate or futile treatment.

A Team-Based Early Action Protocol to Address Ethical Concerns in the Intensive Care Unit

BACKGROUND

Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety.

OBJECTIVE

To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families.

METHODS

In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables.

RESULTS

The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change.

CONCLUSIONS

When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced.

Ethical Concerns Caring for the Stroke Patient

Stroke is a sudden, unexpected illness with an uncertain prognosis for functional recovery. Ethical issues in the care of patients with stroke include assessment of decision-making capacity when cognition or communication is impaired, prognostication, evaluation of quality of life, withdrawal or withholding of life-sustaining treatment, and how to optimize surrogate decision making. Skilled communication between clinicians and patients or their surrogates promotes shared decision making and may prevent ethical conflict. Nurses with an understanding of the ethics of stroke care play an important role in the care of patients with stroke and their families.

Shared Decision-making in Autoimmune Neurology: Making Decisions in the Face of Uncertainty

Purpose of review

In this article, the author explores the use of shared decision making (SDM) in the management of the preference-sensitive condition, neural autoantibody-mediated syndromes.

Recent findings

The field of autoimmune neurology lacks trials and often data to support therapeutic decisions. Treatment choices need to be made acutely, lacking crucial laboratory information and with uncertainty regarding treatment response and prognosis. This lack of data does not necessitate indecision in a population where delayed treatment may lead to poor outcomes. Over the past several decades, SDM has emerged as a model of communication enabling clinicians and their patients to explore current knowledge in the context of a patient's values and goals to arrive at joint decision, even when data are lacking.

Summary

SDM is a tool autoimmune neurologists should use to develop individualized treatment plans based on the patient's clinical presentation contextualized within specific values and preferences.

Management of Helicobacter pylori infection by clinicians: A nationwide survey in a developing country

BACKGROUND & AIMS

Developing countries are making efforts to improve health management. Practice deviating from the guideline means inefficient control. The study aims to investigate the management of Helicobacter pylori (H pylori) infection from a developing country perspective.

METHODS

An authoritative survey was conducted in 14th (2014) and 17th (2017) Congress of Gastroenterology China, respectively. The Maastricht V/Florence consensus report was invoked as the evaluation criterion.

RESULTS

A total of 4182 valid samples were included in this study. Most of the respondents (94%) updated knowledge by lectures. Respondents had a different awareness rate of H pylori-related diseases, ranging from 45% to 95%. Up to 40% of the respondents did not follow the recommendations for the diagnosis. Choice accuracy of eradication regimens and antibiotic combinations was <70%. About 20% of the respondents did not pay attention to the confirmation after the eradication. The situation had been improved in 2017 when compared with that in 2014 (all P < .05). Multivariate logistic regression analysis revealed that influencing factors including nongastroenterologists, bachelor degree and below, the primary professional title, hospital location, and a small proportion of H pylori infection in daily practice related to the deviation of consensus (all P < .05).

CONCLUSIONS

Although the management of H pylori infection has been improved in a developing country, there is still a gap between the real-world practices and the consensus. Influencing factors should be taken into account in decision-making, and the corresponding population should be strengthened with precision training during the promotion of the guideline.

Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

IMPORTANCE

End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.

OBJECTIVE

To determine the changes in end-of-life practices in European ICUs after 16 years.

DESIGN, SETTING, AND PARTICIPANTS

Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.

EXPOSURES

Comparison between the 1999-2000 cohort vs 2015-2016 cohort.

MAIN OUTCOMES AND MEASURES

End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists.

RESULTS

Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001).

CONCLUSIONS AND RELEVANCE

Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.

Variable management strategies for NEC totalis: a national survey

BACKGROUND/OBJECTIVES

Necrotizing enterocolitis (NEC) is a serious disease linked to prematurity. A variant, NEC totalis, is associated with nearly 100% mortality. There is wide variation in counseling practices for NEC totalis. Our objectives are to determine what treatment options, if any, are offered to families, and which factors influence these decisions.

METHODS

An anonymous survey was distributed to members of the AAP Sections on Neonatal-Perinatal Medicine and Pediatric Surgery. Data were analyzed utilizing chi-square tests and Spearman correlations, where applicable.

RESULTS

In the setting of NEC totalis, 90% of the 378 respondents viewed offering life-sustaining interventions (LSI) as ethically permissible and 87% felt that transfer to another center willing to provide LSI should be considered; however, only 43% reported offering LSI to families.

CONCLUSIONS

Management of NEC totalis remains challenging and significant practice variability persists. Most respondents do not offer ongoing medical/surgical management, despite believing it is an ethically permissible option.

Developing an intervention around referral and admissions to intensive care: a mixed-methods study

Background

Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.

Objectives

To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.

Methods

A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.

Results

Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.

Limitations

Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.

Conclusions

Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.

Future work

Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.

Study registration

The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.

Funding

The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

Family ratings of ICU care. Is there concordance within families?

PURPOSE

To examine heterogeneity of quality-of-care ratings within families and to examine possible predictors of concordance.

MATERIALS AND METHODS

We examined two aspects of agreement within families: response similarity and the amount of exact concordance in responses in a cohort of Danish ICU family members participating in a questionnaire survey (the European Quality Questionnaire: euroQ2).

RESULTS

Two hundred seventy-four family respondents representing 122 patients were included in the study. Identical ratings between family members occurred in 28%-59% of families, depending upon the specific survey item. In a smaller sample of 28 families whose patients died, between 39% and 86% gave identical responses to items rating end-of-life care. There was more response variance within than between families, yielding low estimates of intrafamily correlation. Statistics correcting for chance agreement also suggested modest within-family agreement.

CONCLUSIONS

The finding that variance is higher within than between families suggests the value of including multiple participants within a family in order to capture varying points of view.

An international perspective on the frequency, perception of utility, and quality of interprofessional rounds practices in intensive care units

PURPOSE

To describe international variation in interprofessional rounds in intensive care units (ICUs).

MATERIALS AND METHODS

Survey of ICU clinicians on their practices and perceptions of rounds using societal mailing lists and social media.

RESULTS

Out of 2402 respondents, 1752 (72.8%) use rounds. Teams are mostly composed of intensivists, nurses and medical trainees. The majority of rounds (57.5%) last >2 h, and North Americans report the highest rates of rounds allowing family attendance (92.4%). Shorter rounds (1-2 h, OR 0.67, 0.52-0.86, p < 0.01; <1 h, OR 0.72, 0.53-0.97, p = 0.03), and strategies such as designating a person for writing (OR 0.73, 0.57-0.95, p = 0.01), and designating a person to assist other patients (OR 0.75, 0.57-0.98, p = 0.04) are associated with a lower perception of negative outcomes. Using daily goals during rounds is associated with a higher perception of positive outcomes (OR 1.85, 1.17-2.90, p < 0.01).

CONCLUSIONS

Three-quarters of respondents perform rounds, and models of rounds are heterogeneous, creating challenges for future studies on improving rounds. Respondents reporting better outcomes also experience shorter rounds, and adopt strategies such as discussion of daily goals, and designation individuals for writing or assisting other patients during rounds.

Ethics of Outbreaks Position Statement. Part 2: Family-Centered Care

OBJECTIVES

Continue the dialogue presented in Ethics of Outbreaks Position Statement. Part 1, with a focus on strategies for provision of family-centered care in critical illness during Pubic Health Emergency of International Concern.

DESIGN

Development of a Society of Critical Care Medicine position statement using literature review, expert consensus from the Society of Critical Care Medicine Ethics Committee. A family member of a patient who was critically ill during a natural disaster served on the writing panel and provided validation from a family perspective to the recommendations.

SETTING

Provision of family-centered care and support for patients who are critically ill or who have the potential of becoming critically ill, and their families, during a Pubic Health Emergency of International Concern.

INTERVENTIONS

Communication; family support.

MEASUREMENTS AND MAIN RESULTS

Family-centered interventions during a Pubic Health Emergency of International Concern include understanding how crisis standards may affect regional and local traditions. Transparently communicate changes in decision-making authority and uncertainty regarding treatments and outcomes to the family and community. Assess family coping, increase family communication and support, and guide families regarding possible engagement strategies during crisis. Prepare the public to accept survivors returning to the community.

The Theory and Practice of Surrogate Decision-Making

When a patient lacks decision-making capacity and has not left a clear advance directive, there is now widespread agreement that patient-designated and next-of-kin surrogates should implement substituted judgment within a process of shared decision-making. Specifically, after discussing the "best scientific evidence available, as well as the patient's values, goals, and preferences" with the patient's clinicians, the patient-designated or next-of-kin surrogate should attempt to determine what decision the patient would have made in the circumstances. To the extent that this approach works, it seems to provide about as much respect for the autonomy of incapacitated patients as we could ask for. But, as articles in this issue of the Report by Jeffrey Berger and by Ellen Robinson and colleagues emphasize, reality presents challenges.

How Surrogate Decision-Makers for Patients With Chronic Critical Illness Perceive and Carry Out Their Role

OBJECTIVES

Family members commonly make medical decision for patients with chronic critical illness. This study examines how family members approach this decision-making role in real time.

DESIGN

Qualitative analysis of interviews with family members in the intervention arm of a randomized controlled communication trial.

SETTINGS

Medical ICUs at four U.S. hospitals.

PARTICIPANTS

Family members of patients with chronic critical illness (adults mechanically ventilated for ≥ 7 d and expected to remain ventilated and survive for ≥ 72 hr) who participated in the active arm of a communication intervention study.

INTERVENTIONS

Family members participated in at least two content-guided, informational, and emotional support meetings led by a palliative care physician and nurse practitioner.

MEASUREMENTS AND MAIN RESULTS

Grounded theory was used for qualitative analysis of 66 audio recordings of meetings with 51 family members. Family members perceived their role in four main ways: voice of the patient, advocate for the patient, advocate for others, and advocate for oneself. Their decision-making was characterized by balancing goals, sharing their role, keeping perspective, remembering previous experiences, finding sources of strength, and coping with various burdens.

CONCLUSIONS

Family members take a multifaceted approach as they participate in decision-making. Understanding how surrogates perceive and act in their roles may facilitate shared decision-making among clinicians and families during critical care.

Inter-ICU transfer of patients with ventilator dependent respiratory failure: Qualitative analysis of family and physician perspectives

OBJECTIVES

Ventilator dependent respiratory failure (VDRF) patients are seriously ill and often transferred between ICUs. Our objective was to obtain multi-stakeholder insights into the experiences of families during inter-ICU transfer.

METHODS

We conducted a qualitative study using semi-structured interviews with family members of VDRF patients as well as clinicians that have received or transferred VDRF patients to our hospital. Interviews were transcribed and template analysis was used to identify themes within/across stakeholder groups.

RESULTS

Patient, family, clinician and systems-level factors were identified as key themes during inter-ICU transfer. The main findings highlight that family members were rarely engaged in the decision to transfer as well as a lack of standardized communication between clinicians during care transitions. Family members were reassured with the care after transfer in spite of practical and financial challenges. Clinicians acknowledged the lack of a systematic approach for meeting the needs of families and suggested various resources.

CONCLUSIONS

This is one of the first qualitative studies to gather a multi-stakeholder perspective and identify problems faced by families during inter-ICU transfer of VDRF patients.

PRACTICE IMPLICATIONS

Our results provide a starting point for the development of family-centered support interventions which will need to be tested in future studies.

Neurocritical care physicians' doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: an interview study

Background

Multilevel uncertainty exists in the treatment of devastating brain injury and variation in end-of-life decision-making is a concern. Cognitive and emotional doubt linked to making challenging decisions have not received much attention. The aim of this study was to explore physicians´ doubt related to decisions to withhold or withdraw life-sustaining treatment within the first 72 h after devastating brain injury and to identify the strategies used to address doubt.

Method

Semi-structured interviews were conducted with 18 neurocritical care physicians in a Norwegian trauma centre (neurosurgeons, intensivists and rehabilitation specialists) followed by a qualitative thematic analysis.

Result

All physicians described feelings of doubt. The degree of doubt and how they dealt with it varied. Institutional culture, ethics climate and individual physicians´ values, experiences and emotions seemed to impact judgements and decisions. Common strategies applied by physicians across specialities when dealing with uncertainty and doubt were: 1. Provision of treatment trials 2. Using time as a coping strategy 3. Collegial counselling and interdisciplinary consensus seeking 4. Framing decisions as purely medical.

Conclusion

Decisions regarding life-sustaining treatment after devastating brain injury are crafted in a stepwise manner. Feelings of doubt are frequent and seem to be linked to the recognition of fallibility. Doubt can be seen as positive and can foster open-mindedness towards the view of others, which is one of the prerequisites for a good ethical climate. Doubt in this context tends to be mitigated by open interdisciplinary discussions acknowledging doubt as rational and a normal feature of complex decision-making.

Update and recommendations in decision making referred to limitation of advanced life support treatment

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.

Patient-Centered Care and Autonomy: Shared Decision-Making in Practice and a Suggestion for Practical Application in the Critically Ill

Decision-making for the hospitalized dying and critically ill is often characterized by an understanding of autonomy that leads to clinical care and outcomes that are antithetical to patients' preferences around suffering and quality of life. A better understanding of autonomy will facilitate the ultimate goal of a patient-centered approach and ensure compassionate, high-quality care that respects our patients' values. We reviewed the medical literature and our experiences through the ethics service, palliative care service, and critical care service of a large community teaching hospital. The cumulative experience of a senior intensivist was filtered through the lens of a medical ethicist and the palliative care team. The practical application of patient-centered care was discerned from these interactions. We determined that a clearer understanding of patient-centeredness would improve the experience and outcomes of care for our patients as well as our adherence to ethical practice. The practical applications of autonomy and patient-centered care were evaluated by the authors through clinical interactions on the wards to ascertain problems in understanding their meaning. Clarification of autonomy and patient-centeredness is provided using specific examples to enhance understanding and application of these principles in patient-centered care.

Teamwork When Conducting Family Meetings: Concepts, Terminology, and the Importance of Team-Team Practices

Family meetings, which bring together members of a seriously ill patient's family and the interprofessional team (IPT), have been widely recognized as promoting shared decision-making for hospitalized patients, particularly those in intensive care units. The planning and conducting of interprofessional family meetings are hampered, however, by a lack of clarity about who is doing what and when, which in turn can lead to inefficiencies and uncoordinated efforts. This article describes how members of the IPT interact with one another (what we have termed team-team practices), distinguishing these interactions from how the IPT engages directly with family members (team-family practices) in preparing for and conducting family meetings. Although most research and guidelines have focused on team-family practices that directly affect patient- and family-level outcomes (e.g., safety and satisfaction), team-team practices are needed to coordinate team contributions and optimize the skills of the diverse team. Team members' knowledge and attitudes also contribute to patient and family outcomes as well as team outcomes. Yet without attention to team-team practices before, during, and after a family meeting, the family-level outcomes are less likely to be achieved as are team well-being outcomes (e.g., reduced burnout and staff retention). Drawing upon team theory, we present a set of key concepts and corresponding terms that enable a more precise description of team-team practices and team-family practices, aiming to help with team training and evaluation and to enable future research of these distinct yet inter-related practices.

The quality of dying and death for patients in intensive care units: a single center pilot study

BACKGROUND

To identify the necessary care for dying patients in intensive care units (ICUs), we designed a retrospective study to evaluate the quality of dying and death (QODD) experienced by the surrogates of patients with medical illness who died in the ICU of a tertiary referral hospital.

METHODS

To achieve our objective, the authors compared the QODD scores as appraised by the relatives of patients who died of cancer under hospice care with those who died in the ICU. For this study, a Korean version of the QODD questionnaire was developed, and individual interviews were also conducted.

RESULTS

Sixteen people from the intensive care group and 23 people from the hospice care group participated in the survey and completed the questionnaire. The family members of patients who died in the ICU declined participation at a high rate (50%), with the primary reason being to avoid bringing back painful memories (14 people, 87.5%). The relatives of the intensive care group obtained an average total score on the 17-item QODD questionnaire, which was significantly lower than that of the relatives of the hospice group (48.7±15.5 vs. 60.3±14.8, P=0.03).

CONCLUSIONS

This work implies that there are unmet needs for the care of dying patients and for the QODD in tertiary hospital ICUs. This result suggests that shared decision making for advance care planning should be encouraged and that education on caring for dying patients should be provided to healthcare professionals to improve the QODD in Korean ICUs.

End-of-life Considerations and Shared Decision Making in Neurocritical Care

The goal of shared decision making in the neurocritical care setting is to form plans of care that are consistent with best medical practice and are respectful of the patient's values. Close cooperation and meaningful interaction must be achieved with family members so that the patient's "person can emerge" through discussions. This article highlights several caveats that can subvert this complex process, including the cognitive biases that affect both clinicians and surrogates. Impact, optimism, and gain-framing biases may be particularly relevant when considering patients who are receiving neurocritical care. Practitioners need to be cognizant of the distorting influences of these biases and make attempts to neutralize them. Quality of survival and the nature and degree of deficits are often the dominant concerns after patients experience acute severe brain injuries. Care should be taken to avoid conflating medical facts and value judgments when discussing prognoses.

Evaluation of Implementation Outcomes After Initiation of a Shared Decision-making Program for Men With Prostate Cancer

OBJECTIVE

To evaluate barriers to implementation of patient decision aids (PDAs) issued in an electronic medical record (EMR). We undertook an implementation outcomes analysis focused on what proportion of men eligible for the PDA received it (penetration), and of the men who received it, how many used it as intended (fidelity). We also evaluated various patient-centered outcomes related to decision-making.

MATERIALS AND METHODS

Men with incident localized prostate cancer were recruited from at UCLA from 2013 to 2017. PDA eligibility was determined via weekly EMR review. We also performed a retrospective chart review of all patients seen in clinic for one sample week to identify patients that were missed by the initial eligibility algorithm, and investigated the cause for miscategorization. We analyzed differences in patient-centered outcomes between those who did and did not receive the PDA.

RESULTS

About 314/374 men with incident prostate cancer completed the PDA conferring 84% fidelity. PDA penetration under initial identification prospective algorithm was assessed at 100% (n = 2/n = 2). However, penetration assessed by manual retrospective chart review was 20% (n = 2/n = 10). Improvements to the identification algorithm, including new EMR visit types, were identified. PDA completion was associated with less decisional conflict and higher perceived Shared decision-making (all P<.03).

CONCLUSION

No previous studies have investigated the challenges of implementing a PDA facilitated by the EMR. We identified modifiable system and EMR-related factors that limited program penetration. Our PDA showed decisional quality benefits.

Factors associated with physicians' predictions of six-month mortality in critically ill patients

Background

Physician's estimates of a patient's prognosis are an important component in shared decision-making. However, the variables influencing physician's judgments are not well understood. We aimed to determine which physician and patient factors are associated with physicians' predictions of critically ill patients' six-month mortality and the accuracy and confidence of these predictions.

Methods

Prospective cohort study evaluating physicians' predictions of six-month mortality. Using univariate and multivariable generalized estimating equations, we assessed the association between baseline physician and patient characteristics with predictions of six-month death, as well as accuracy and confidence of these predictions.

Results

Our cohort was comprised 300 patients and 47 physicians. Physicians were asked to predict if patients would be alive or dead at six months and to report their confidence in these predictions. Physicians predicted that 99 (33%) patients would die. The key factors associated with both the direction and accuracy of prediction were older age of the patient, the presence of malignancy, being in a medical ICU, and higher APACHE III scores. The factors associated with lower confidence included older physician age, being in a medical ICU and higher APACHE III score.

Conclusions

Patient level factors are associated with predictions of mortality at six months. The accuracy and confidence of the predictions are associated with both physician and patients' factors. The influence of these factors should be considered when physicians reflect on how they make predictions for critically ill patients.

Intensive care unit length of stay is reduced by protocolized family support intervention: a systematic review and meta-analysis

PURPOSE

This study aimed to elucidate the impact of protocolized family support intervention on length of stay (LOS) in the intensive care unit (ICU) through a systematic review and meta-analysis.

METHODS

Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and other web-based databases were referenced since inception until November 26, 2018. We included randomized-controlled trials wherein protocolized family support interventions were conducted for enhanced communication and shared medical decision-making. LOS (in days) and mortality were evaluated using a random-effects model, and adjusted LOS was estimated using a mixed-effects model.

RESULTS

We included seven randomized-controlled trials with 3477 patients. Protocolized family support interventions were found to significantly reduce the ICU LOS {mean difference = - 0.89 [95% confidence interval (CI) = - 1.50 to - 0.27]} and hospital LOS [mean difference = - 3.78 (95% CI = - 5.26 to - 2.29)]; the results of the mixed-effect model showed that they significantly reduced ICU LOS after adjusting for the therapeutic goal [mean difference = - 1.30 (95% CI = - 2.35 to - 0.26)], methods of measurement [mean difference = - 0.89 (95% CI = - 1.55 to - 0.22)], and timing of intervention [mean difference = - 1.05 (95% CI = - 2.05 to - 0.05)]. Similar results were found after adjusting for patients' disease severity [mean difference = - 1.21 (95% CI = - 2.03 to - 0.39)] and the trim-and-fill method [mean difference = - 0.86 (95% CI = - 1.44 to - 0.28)]. There was no difference in mortality rate in ICU and hospital between the protocolized intervention and control groups.

CONCLUSIONS

Protocolized family support intervention for enhanced communication and shared decision-making with the family reduced ICU LOS in critically ill patients without impacting mortality.