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

Association of Surrogate Decision-making Interventions for Critically Ill Adults With Patient, Family, and Resource Use Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

Physicians often rely on surrogate decision-makers (SDMs) to make important decisions on behalf of critically ill patients during times of incapacity. It is uncertain whether targeted interventions to improve surrogate decision-making in the intensive care unit (ICU) reduce nonbeneficial treatment and improve SDM comprehension, satisfaction, and psychological morbidity.

OBJECTIVE

To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) to determine the association of such interventions with patient- and family-centered outcomes and resource use.

DATA SOURCES

A search was conducted of MEDLINE, Embase, and other relevant databases for potentially relevant studies from inception through May 30, 2018.

STUDY SELECTION

Randomized clinical trials studying interventions that were targeted at SDMs or family members of critically ill adults in the ICU were included. Key search terms included surrogate or substitute decision-maker, critically ill, randomized controlled trials, and their respective related terms.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent, blinded reviewers independently screened citations and extracted data. Random effects models with inverse variance weighting were used to pool outcomes data when possible and otherwise present findings qualitatively.

MAIN OUTCOMES AND MEASURES

Outcomes of interest were divided into 3 categories: (1) patient-related clinical outcomes (mortality, length of stay [LOS], duration of life-sustaining therapies), (2) SDM and family-related outcomes (comprehension, major change in goals of care, incident psychological comorbidities [posttraumatic stress disorder, anxiety, depression], and satisfaction with care), and (3) use of resources (cost of care and health care resource use).

RESULTS

Of 3735 studies screened, 13 RCTs were included, comprising a total of 10 453 patients. Interventions were categorized as health care professional led (n = 6), ethics consultation (n = 3), palliative care consultation (n = 2), and media (n = 1 pamphlet and 1 video). No association with mortality was observed (risk ratio, 1.03; 95% CI, 0.98-1.08; P = .22). Intensive care unit LOS was significantly shorter among patients who died (mean difference, -2.11 days; 95% CI, -4.16 to -0.07; P = .04), but not in the overall population (mean difference, -0.79 days; 95% CI, -2.33 to 0.76 days; P = .32). There was no consistent difference in SDM-related outcomes, including satisfaction with care or perceived quality of care (n = 6 studies) and incident psychological comorbidities (depression: ratio of means, -0.11; 95% CI, -0.29 to 0.08; P = .26; anxiety: ratio of means, -0.08; 95% CI, -0.25 to 0.08; P = .31; or posttraumatic stress disorder: ratio of means: -0.04; 95% CI, -0.21 to 0.13; P = .65). Among 6 trials reporting effects on health care resource use, only 1 nurse-led intervention observed a significant reduction in costs ($75 850 control vs $51 060 intervention; P = .04).

CONCLUSIONS AND RELEVANCE

Systematic interventions aimed at improving surrogate decision-making for critically ill adults may reduce ICU LOS among patients who die in the ICU, without influencing overall mortality. Better understanding of the complex processes related to surrogate decision-making is needed.

Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals

For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.

Correlates of Cognitive Load in Surrogate Decision Makers of the Critically III

Surrogate decision makers (SDMs) of the critically ill experience intense emotions and transient states of decision fatigue. These factors may increase the cognitive load experienced by electronic decision aids. This cross-sectional study explored the associations of emotion regulation (expressive suppression and cognitive reappraisal) and decision fatigue with cognitive load (intrinsic and extraneous) among a sample of 97 SDMs of the critically ill. After completing subjective measures of emotion regulation and decision fatigue, participants were exposed to an electronic decision aid and completed a subjective measurement of cognitive load. Multiple regression analyses indicated that decision fatigue predicted intrinsic cognitive load and expressive suppression predicted extraneous cognitive load. Emotion regulation and decision fatigue represent modifiable determinants of cognitive load among SDMs exposed to electronic decision aids.

Comfort care in trauma patients without severe head injury: In-hospital complications as a trigger for goals of care discussions

INTRODUCTION

Many injured patients or their families make the difficult decision to withdraw life-sustaining therapies (WLST) following severe injury. While this population has been studied in the setting of severe traumatic brain injury (TBI), little is known about patients who undergo WLST without TBI. We sought to describe patients who may benefit from early involvement of end-of-life resources.

METHODS

Trauma Quality Improvement Program (2013-2014) patients who underwent WLST were identified. WLST patients were compared to those who died with full supportive care (FSC). Patients were excluded for death within 24 h of admission, or head AIS > 3. Intergroup comparisons were by student's t tests or Wilcoxon rank sum tests; significance for p < 0.05.

RESULTS

We identified 3471 total injured patients without major TBI who died > 24 h after admission. Of these death after WLST occurred in 2301 (66% of total). This group had a mean age of 66.8 years; 35.7% were women, and 95.4% sustained blunt injury. WLST patients had a higher ISS (21.6 vs. 12.5, p = 0.001), more in-hospital complications (71.4% vs. 41.6%, p = < 0.0001), and a longer ICU length of stay (8.9 days vs. 7.5 days, p = <0.0001) compared to patients who died with FSC.

CONCLUSION

WLST occurs in two-thirds of injured patients without severe TBI who die in the hospital. In-hospital complications are more frequent in this patient group than those who die with FSC. Early palliative care consultation may improve patient and family satisfaction after acute injury when the timeframe to leverage such services is significantly condensed.

We don't need unilateral DNRs: taking informed non-dissent one step further

Although shared decision-making is a standard in medical care, unilateral decisions through process-based conflict resolution policies have been defended in certain cases. In patients who do not stand to receive proportional clinical benefits, the harms involved in interventions such as cardiopulmonary resuscitation seem to run contrary to the principle of non-maleficence, and provision of such interventions may cause clinicians significant moral distress. However, because the application of these policies involves taking choices out of the domain of shared decision-making, they face important ethical and legal problems, including a recent challenge to their constitutionality. In light of these concerns, we suggest a re-conceptualization of informed non-dissent as an alternative approach in cases where the application of process-based policies is being considered. This clinician-directed communication model still preserves what is valuable in such policies and salvages professional integrity, while minimising ethical and legal challenges.

Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units

IMPORTANCE

Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating intensive care unit (ICU) patients' values and preferences into treatment decisions.

OBJECTIVES

To determine how often clinicians and surrogates exchange information about patients' previously expressed values and preferences and deliberate and plan treatment based on these factors during conferences about prognosis and goals of care for incapacitated ICU patients.

DESIGN, SETTING, AND PARTICIPANTS

A secondary analysis of a prospective, multicenter cohort study of audiorecorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults was conducted. The study was performed between October 8, 2009, and October 23, 2012. Data analysis was performed between July 2, 2014, and April 20, 2015. Patient eligibility criteria included lack of decision-making capacity, a diagnosis of acute respiratory distress syndrome, and predicted in-hospital mortality of 50% or more. In addition to the patients, 451 surrogates and 144 clinicians at 13 ICUs at 6 US academic and community medical centers were included.

MAIN OUTCOMES AND MEASURES

Two coders analyzed transcripts of audiorecorded conversations for statements in which clinicians and surrogates exchanged information about patients' treatment preferences and health-related values and applied them in deliberation and treatment planning.

RESULTS

Of the 249 patients, 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%; 95% CI, 20.3%-31.3%) contained no information exchange or deliberation about patients' values and preferences. Clinicians and surrogates exchanged information about patients' values and preferences in 167 (68.4%) (95% CI, 62.6%-74.3%) of the conferences and specifically deliberated about how the patients' values applied to the decision in 108 (44.3%; 95% CI, 38.0%-50.5%). Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 87 (35.7%) or less of the conferences; surrogates provided a substituted judgment in 33 (13.5%); and clinicians made treatment recommendations based on patients' values and preferences in 20 conferences (8.2%).

CONCLUSIONS AND RELEVANCE

Most clinician-family conferences about prognosis and goals of care for critically ill patients appear to lack important elements of communication about values and preferences, with robust deliberation being particularly deficient. Interventions may be needed to better prepare surrogates for these conversations and improve clinicians' communication skills for eliciting and incorporating patients' values and preferences into treatment decisions.

Physician Approaches to Conflict with Families Surrounding End-of-Life Decision-making in the Intensive Care Unit. A Qualitative Study

RATIONALE

Families of critically ill patients are often asked to make difficult decisions to pursue, withhold, or withdraw aggressive care or resuscitative measures, exercising "substituted judgment" from the imagined standpoint of the patient. Conflict may arise between intensive care unit (ICU) physicians and family members regarding the optimal course of care.

OBJECTIVES

To characterize how ICU physicians approach and manage conflict with surrogates regarding end-of-life decision-making.

METHODS

Semistructured interviews were conducted with 18 critical care physicians from four academically affiliated hospitals. Interview transcripts were analyzed using methods of grounded theory.

RESULTS

Physicians described strategies for engaging families to resolve conflict about end-of-life decision-making and tending to families' emotional health. Physicians commonly began by gauging family receptiveness to recommendations from the healthcare team. When faced with resistance to recommendations for less aggressive care, approaches ranged from deference to family wishes to various persuasive strategies designed to change families' minds, and some of those strategies may be counterproductive or harmful. The likelihood of deferring to family in the event of conflict was associated with the perceived sincerity of the family's "substituted judgment" and the ability to control patient pain and suffering. Physicians reported concern for the family's emotional needs and made efforts to alleviate the burden on families by assuming decision-making responsibility and expressing nonabandonment and commitment to the patient. Physicians were attentive to repairing damage to their relationship with the family in the aftermath of conflict. Finally, physicians described their own emotional responses to conflict, ranging from frustration and anxiety to satisfaction with successful resolution of conflict.

CONCLUSIONS

Critical care physicians described a complex and multilayered approach to physician-family conflict. The reported strategies offer insight into pragmatic approaches to achieving resolution of conflict while attending to both family and physician emotional impact, and they also highlight some potentially unhelpful or harmful behaviors that should be avoided. Further research is needed to evaluate how these strategies are perceived by families and other ICU clinicians and how they affect patient, family, and clinician outcomes.

Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation: A Randomized Clinical Trial

Background

Treatment decisions commonly have to be made in intensive care units (ICUs). These decisions are difficult for surrogate decision makers and often lead to decisional conflict, psychological distress, and treatments misaligned with patient preferences.

Objective

To determine whether a decision aid about prolonged mechanical ventilation improved prognostic concordance between surrogate decision makers and clinicians compared with a usual care control.

Design

Multicenter, parallel, randomized, clinical trial. (ClinicalTrials.gov: NCT01751061).

Setting

13 medical and surgical ICUs at 5 hospitals.

Participants

Adult patients receiving prolonged mechanical ventilation and their surrogates, ICU physicians, and ICU nurses.

Intervention

A Web-based decision aid provided personalized prognostic estimates, explained treatment options, and interactively clarified patient values to inform a family meeting. The control group received information according to usual care practices followed by a family meeting.

Measurements

The primary outcome was improved concordance on 1-year survival estimates, measured with the clinician-surrogate concordance scale (range, 0 to 100 percentage points; higher scores indicate more discordance). Secondary and additional outcomes assessed the experiences of surrogates (psychological distress, decisional conflict, and quality of communication) and patients (length of stay and 6-month mortality). Outcomes assessors were blinded to group allocation.

Results

The study enrolled 277 patients, 416 surrogates, and 427 clinicians. Concordance improvement did not differ between intervention and control groups (mean difference in score change from baseline, -1.7 percentage points [95% CI, -8.3 to 4.8 percentage points]; P = 0.60). Surrogates' postintervention estimates of patients' 1-year prognoses did not differ between intervention and control groups (median, 86.0% [interquartile range {IQR}, 50.0%] vs. 92.5% [IQR, 47.0%]; P = 0.23) and were substantially more optimistic than results of a validated prediction model (median, 56.0% [IQR, 43.0%]) and physician estimates (median, 50.0% [IQR, 55.5%]). Eighty-two intervention surrogates (43%) favored a treatment option that was more aggressive than their report of patient preferences. Although intervention surrogates had greater reduction in decisional conflict than control surrogates (mean difference in change from baseline, 0.4 points [CI, 0.0 to 0.7 points]; P = 0.041), other surrogate and patient outcomes did not differ.

Limitation

Contamination among clinicians could have biased results toward the null hypothesis.

Conclusion

A decision aid about prolonged mechanical ventilation did not improve prognostic concordance between clinicians and surrogates, reduce psychological distress among surrogates, or alter clinical outcomes. Decision support in acute care settings may require greater individualized attention for both the cognitive and affective challenges of decision making.

Primary Funding Source

National Institutes of Health.

Development and Pilot Testing of a Simulation to Study How Physicians Facilitate Surrogate Decision Making Based on Critically Ill Patients' Values and Preferences

CONTEXT

There are no evidence-based programs to train physicians to facilitate shared decision making based on incapacitated intensive care unit patients' values and preferences.

OBJECTIVES

The objective of this study was to develop a high-fidelity simulation to fill this gap.

METHODS

Case development involved six steps: 1) drafting a case about an elderly patient receiving prolonged mechanical ventilation; 2) engaging an expert advisory board to optimize case content; 3) revising the case based on advisory board input; 4) training actors to portray the case patient's daughter; 5) obtaining physician feedback on the simulation; and 6) revising the case based on their feedback. We conducted a cross-sectional pilot study with 50 physicians to assess feasibility and acceptability, defined a priori as an enrollment rate >40 physicians/year, study procedures <75 minutes/participant, >95% actor adherence to standardization rules, and high physician ratings of realism and acceptability.

RESULTS

Advisory panel feedback yielded two modifications: 1) refocusing the case on decision making about tracheostomy and percutaneous gastrostomy and 2) making the patient's values more authentic. Physician feedback yielded two additional modifications: 1) reducing how readily the actor divulged the patient's values and 2) making her more emotional. All 50 physicians enrolled in the pilot study over 11 months completed study procedures in <75 minutes. Actor adherence to standardization rules was 95.8%. Physicians' mean ratings of realism and acceptability were 8.4 and 9.1, respectively, on a 10-point scale.

CONCLUSION

Simulation is feasible, is acceptable, and can be adequately standardized to study physicians' skills for facilitating surrogate decision making based on an incapacitated intensive care unit patient's values and preferences.

Feasibility and Effectiveness of a Mnemonic Approach to Teach Residents How to Assess Goals of Care

Background: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together. There is an imperative to teach young physicians early in their training the importance of engaging in a shared decision-making process to define overall goals of care (GOC). The PERSON mnemonic proposes a structured format that allows providers to evaluate GOC across the spectrum of serious illnesses, outside of breaking bad news or end-of-life planning. Objectives: This study evaluated the utility of the PERSON mnemonic in training residents to have GOC with their patients, and investigated if these skills translated to the bedside with real patient encounters. Methods: First-year residents were divided into groups to participate in an in-depth education session. A pre-/postbaseline survey was administered immediately after the education intervention and approximately seven months later to assess retention and utility. Results: Thirty first-year residents were eligible for this study; 30 attended the educational sessions and completed the immediate baseline pre-/postsurvey and the seven-month follow-up survey, resulting in 100% retention rate throughout study. Residents found sustained utility in the mnemonic. It was significantly successful in increasing the knowledge and confidence level in exploring GOC. Patient-centered outcomes could not be analyzed due to low response rates and limited granularity of hospital-level data. Conclusion: The PERSON mnemonic is a feasible and useful format for teaching residents how to have a GOC discussion.

More than one in three proxies do not know their loved one's current code status: An observational study in a Maryland ICU

Rationale

The majority of ICU patients lack decision-making capacity at some point during their ICU stay. However the extent to which proxy decision-makers are engaged in decisions about their patient’s care is challenging to quantify.

Objectives

To assess 1)whether proxies know their patient’s actual code status as recorded in the electronic medical record (EMR), and 2)whether code status orders reflect ICU patient preferences as reported by proxy decision-makers.

Methods

We enrolled proxy decision-makers for 96 days starting January 4, 2016. Proxies were asked about the patient’s goals of care, preferred code status, and actual code status. Responses were compared to code status orders in the EMR at the time of interview. Characteristics of patients and proxies who correctly vs incorrectly identified actual code status were compared, as were characteristics of proxies who reported a preferred code status that did vs did not match actual code status.

Measurements and main results

Among 111 proxies, 42 (38%) were incorrect or unsure about the patient’s actual code status and those who were correct vs. incorrect or unsure were similar in age, race, and years of education (P>0.20 for all comparisons). Twenty-nine percent reported a preferred code status that did not match the patient’s code status in the EMR. Matching preferred and actual code status was not associated with a patient’s age, gender, income, admission diagnosis, or subsequent in-hospital mortality or with proxy age, gender, race, education level, or relation to the patient (P>0.20 for all comparisons).

Conclusions

More than 1 in 3 proxies is incorrect or unsure about their patient’s actual code status and more than 1 in 4 proxies reported that a preferred code status that did not match orders in the EMR. Proxy age, race, gender and education level were not associated with correctly identifying code status or code status concordance.

A Japanese version of the Patient Attitudes and Beliefs Scale for patients with musculoskeletal disorders

Background: The Patient Attitudes and Beliefs Scale (PABS) is a self-reporting questionnaire with 12 items on a 5-point Likert scale for patient's attitude towards shared decision making but its adaptation into Japanese has not been undertaken. Objectives: To develop a Japanese version of the PABS (PABS-J) through translation into Japanese and evaluation of an appropriate scoring system and unidimensionality using Rasch analysis and test-retest reliability. Design: This study included a cross-cultural validation step and investigations of questionnaire validity and reliability. Method: One-hundred-ten patients with musculoskeletal disorders referred to physiotherapy completed the Japanese draft of the PABS before the initial session of physiotherapy. Seventy-five of the 110 participants completed the PABS twice, on a separate day. Items that violated pre-determined criteria of unidimensionality and test-retest reliability (Quadratic-weighted κ ≦ 0.4) were removed. Further, the 110 participants identified one of the four stages of readiness towards shared decision making and correlation with the score of the PABS-J was preliminarily investigated as concurrent validity. Results/Findings: Rasch analysis confirmed unidimensionality of six items and appropriateness of a 3-point scale. Moderate test-retest reliability of the PABS-J was detected (Intra-class correlation coefficient = 0.70). A statistically significant and positive but weak correlation between the PABS-J scores and the four stages of readiness towards shared decision making was detected (ρ = 0.20, P = 0.03). Conclusions: The current study demonstrated partial validity and reliability of the PABS-J with six items and 3-point scale. This questionnaire will be a foundation for further investigations attitude towards shared decision making.

Need for psychological support in intensive care : A survey among members of the German Society of Medical Intensive Care and Emergency Medicine

A high incidence of care-relevant psychological problems in critical care medicine has been reported among patients, their families and professional care givers. International guidelines give appropriate recommendations for such care. What is unclear, however, is just how the care and support are provided in day-to-day practice and, in particular, which service providers are responsible for this support. The present care situation was studied in a web-based survey (38% response rate) among all members of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN). Most respondents reported a moderate to substantial need for psychological support of patients in intensive care and a substantial to very substantial need in the case of their family members. The need for support in the case of staff showed a relatively broad scatter in the assessment. Providers of care are mainly the members of the intensive care team themselves, while clinical pastoral counsellors in particular are also involved and, to a lesser extent, counselling or liaison services specializing in psychotherapy.

Perils of the Hidden Curriculum: Emotional Labor and "Bad" Pediatric Proxies

Today's medical training environment exposes medical trainees to many aspects of what has been called "the hidden curriculum." In this article, we examine the relationship between two aspects of the hidden curriculum, the performance of emotional labor and the characterization of patients and proxies as "bad," by analyzing clinical ethics discussions with resident trainees at an academic medical center. We argue that clinicians' characterization of certain patients and proxies as "bad," when they are not, can take an unnecessary toll on trainees' emotions. We conclude with a discussion of how training in ethics may help uncover and examine these aspects of the hidden curriculum.

Decision-making in ICU - A systematic review of factors considered important by ICU clinician decision makers with regard to ICU triage decisions

BACKGROUND

The ICU is a scarce resource within a high-stress, high-stakes, time-sensitive environment where critically ill patients with life-threatening conditions receive expensive life-sustaining care under the guidance of expert qualified personnel. The implications of decisions such as suitability for admission into ICU are potentially dire and difficult.

OBJECTIVES

To conduct a systematic review of clinicians' subjective perceptions of factors that influence the decision to accept or refuse patients referred to ICU.

RESULTS

Twenty studies yielded 56 different factors classified into patient, physician and environmental. Common, important factors were: acute illness severity and reversibility; presence and severity of comorbidities; patient age, functional status, state-of-mind and wishes; physician level of experience and perception of patient QOL; and bed availability. Within-group variability among physicians and thought-deed discordance were demonstrated.

CONCLUSIONS

The complex and dynamic ICU triage decision is affected by numerous interacting factors. The literature provides some indication of these factors, but fail to show complexities and interactions between them. A decision tree is proposed. Further research should include a reflection on how decisions for admission to ICU are made, such that a better understanding of these processes can be achieved allowing for improved individual and group consistency.

Making a Connection: Family Experiences With Bedside Rounds in the Intensive Care Unit

BACKGROUND

The hospitalization of a family member in an intensive care unit can be stressful for the family. Family bedside rounds is a way for the care team to inform family members, answer questions, and involve them in care decisions. The experiences of family members with intensive care unit bedside rounds have been examined in few studies.

OBJECTIVES

To describe (1) the experiences of family members of patients in the intensive care unit who participated in family bedside rounds (ie, view of the illness, role in future management, and long-term consequences on individual and family functioning) and (2) the experiences of families who chose not to participate in family bedside rounds and their perspectives regarding its value, their illness view, and future involvement in care.

METHODS

A qualitative descriptive study was done, undergirded by the Family Management Style Framework, examining families that participated and those that did not.

RESULTS

Most families that participated (80%) found the process helpful. One overarching theme, Making a Connection: Comfort and Confidence, emerged from participating families. Two major factors influenced how that connection was made: consistency and preparing families for the future. Three types of consistency were identified: consistency in information being shared, in when rounds were being held, and in informing families of rounding delays. In terms of preparing families for the future, families appeared to feel comfortable with the situation when a connection was present. When any of the factors were missing, families described feelings of anger, frustration, and fear. Family members who did not participate described similar feelings and fear of the unknown because of not having participated.

CONCLUSION

What health care providers say to patients' families matters. Families may need to be included in decision-making with honest, consistent, easy-to-understand information.

A comparison of the opinions of intensive care unit staff and family members of the treatment intensity received by patients admitted to an intensive care unit: A multicentre survey

BACKGROUND

Achieving shared decision-making in the intensive care unit (ICU) is challenging because of limited patient capacity, leading to a reliance on surrogate decision-makers. Prior research shows that ICU staff members often perceive that patients receive inappropriate or futile treatments while some surrogate decision-makers of patients admitted to the ICU report inadequate communication with physicians. Therefore, understanding the perceptions of both ICU staff and surrogate decision-makers around wishes for ICU treatments is an essential component to improve these situations.

OBJECTIVES

The objectives of this study were to compare perceptions of ICU staff with surrogate decision-makers about the intensity and appropriateness of treatments received by patients and analyse the causes of any incongruence.

METHODS

A multicentred, single-day survey of staff and surrogate decision-makers of ICU inpatients was conducted across four Australian ICUs in 2014. Patients were linked to a larger prospective observational study, allowing comparison of patient outcomes.

RESULTS

Twelve of 32 patients were identified as having a mismatch between staff and surrogate decision-maker perceptions. For these 12 patients, all 12 surrogate decision-makers believed that the treatment intensity the patient was receiving was of the appropriate intensity and duration. Mismatched patients were more likely to be emergency admissions to ICU compared with nonmismatched patients (0.0% vs 42.1%, p = 0.012) and have longer ICU admissions (7.5 vs 3, p = 0.022). There were no significant differences in perceived communication (p = 0.61).

CONCLUSIONS

Family members did not share the same perceptions of treatment with ICU staff. This may result from difficulty in prognostication; challenges in conveying poor prognoses to surrogate decision-makers; and the accuracy of surrogate decision-makers.

Patient and Provider Perspectives on a Decision Aid for Familial Hypercholesterolemia

Familial Hypercholesterolemia (FH) is an inherited disorder associated with increased cardiovascular risk that requires patients to make multiple impactful decisions regarding the management of their condition. Patient decision aids (PDAs) can facilitate shared decision-making (SDM) and enable patients to make choices that are concordant with their goals and values. To inform the development of a PDA for patients with FH, we employed a qualitative inductive approach and focus group discussions with patients, physicians, and genetic counselors. We explored and analyzed the perceptions and understanding of these stakeholders related to a PDA for FH and identified important concepts to include in the PDA. Categories emerging from focus group discussions included: (a) perceptions of a PDA related to FH; (b) discussion about the content of a PDA related to FH; and (c) SDM. In general, stakeholders were in favor of developing tools which can inform and individualize discussion about genetic testing and treatment options for FH. Physicians valued a tool that facilitates knowledge transfer to FH patients. Patients desired a tool to help them understand the genetic aspects of and treatment options related to FH. Genetic counselors emphasized the inclusion of visual aids to support discussion with patients. Potential barriers to and facilitators of PDA implementation were identified. The input of various stakeholders will inform the development of a prototype tool that will be iteratively tested before implementation in the clinical setting.

Shared Decision-making in Pediatric Practice: A Broad View

In 1982, the Presidential Commission published its seminal report, Making Health Care Decisions, advocating for informed medical decision-making shared between the patient and health care providers that is sensitive to patient values and goals. Over the past 2 decades, multiple professional organizations have officially supported shared decision-making (SDM); however, there remains no unified, well-accepted definition of the term. One reason for the lack of consensus is the wide array of clinical settings and patient populations. SDM in pediatric practice can be complicated because of the inclusion of the child in the decision-making team and the duties and limits of parental decision-making authority. The authors in this supplement provide a broad view of SDM in the pediatric setting. Many of the authors raise important questions and delineate some of the challenges that lie ahead. We hope that the articles foster further conversation and spur research to improve SDM and the care we provide to children and families.

Titrating Clinician Directiveness in Serious Pediatric Illness

Shared decision-making in pediatrics is based on a trusting partnership between parents, clinicians, and sometimes patients, wherein all stakeholders explore values and weigh options. Within that framework, clinicians often have an obligation to provide guidance. We describe a range of ethically justifiable clinician directiveness that could be appropriate in helping families navigate serious pediatric illness. The presentation of "default" options and informed nondissent as potential strategies are discussed. The degree of clinician directiveness may vary even for decisions that are equally "shared." A myriad of factors affect how directive a clinician can or should be. Some of the most important factors are the degree of prognostic certainty and the family's desire for guidance, but others are important as well, such as the urgency of the decision; the relationship between the clinician, patient, and family; the degree of team consensus; and the burdens and benefits of therapy. Directiveness should be considered an important tool in a clinician's armamentarium and is one that can be used to support families in stressful and emotionally difficult situations.

Supporting Family Decision-making for a Child Who Is Seriously Ill: Creating Synchrony and Connection

The families of children with chronic or serious illness are sometimes faced with difficult decisions never previously imagined. We offer a stepwise approach in building a human connection with these families to support them through the decision-making process. We encourage the clinician to stop talking and to actively listen and find common ground. We suggest that offering open and honest information begins with an invitation. We encourage clinicians to explore concepts with the family, including their fears and hopes. We discuss nurturing an emotional connection between the child and family and describe ways to discover a family's preference for involvement in the decision-making process. Central to supporting a family is to place infinite value on the life of their child. We argue that attention to these matters will help the clinician remain in sync with the family to ensure meaningful and high-quality decision-making during highly vulnerable times for families.

New perspectives on substituted relational autonomy for shared decision-making in critical care

In critical care when unconscious patients are assisted by machines, humanity is mainly ensured by respect for autonomy, realised through advance directives or, mostly, reconstructed by cooperation with relatives. Whereas patient-centred approaches are widely discussed and fostered, managing communication in complex, especially end-of-life, situations in open intensive care units is still a point of debate and a possible source of conflict and moral distress. In particular, healthcare teams are often sceptical about the growing role of families in shared decision-making and their ability to represent patients’ preferences. New perspectives on substituted relational autonomy are needed for overcoming this climate of suspicion and are discussed through recent literature in the field of medical ethics.

Inter-Rater Agreement of Intensivists Evaluating the Goal Concordance of Preference-Sensitive ICU Interventions

CONTEXT

Goal-concordant care has been identified as an important outcome of advance care planning and shared decision-making initiatives. However, validated methods for measuring goal concordance are needed.

OBJECTIVES

To estimate the inter-rater reliability of senior critical care fellows rating the goal concordance of preference-sensitive interventions performed in intensive care units (ICUs) while considering patient-specific circumstances as described in a previously proposed methodology.

METHODS

We identified ICU patients receiving preference-sensitive interventions in three adult ICUs at Johns Hopkins Hospital. A simulated cohort was created by randomly assigning each patient one of 10 sets of goals and preferences about limiting life support. Critical care fellows then independently reviewed patient charts and answered two questions: 1) Is this patient's goal achievable? and 2) Will performing this intervention help achieve the patient's goal? When the answer to both questions was yes, the intervention was rated as goal concordant. Inter-rater agreement was summarized by estimating intraclass correlation coefficient using mixed-effects models.

RESULTS

Six raters reviewed the charts of 201 patients. Interventions were rated as goal concordant 22%-92% of the time depending on the patient's goal-limitation combination. Percent agreement between pairs of raters ranged from 59% to 86%. The intraclass correlation coefficient for ratings of goal concordance was 0.50 (95% CI 0.31-0.69) and was robust to patient age, gender, ICU, severity of illness, and lengths of stay.

CONCLUSION

Inter-rater agreement between intensivists using a standardized methodology to evaluate the goal concordance of preference-sensitive ICU interventions was moderate. Further testing is needed before this methodology can be recommended as a clinical research outcome.

Shared Decision Making in Neurocritical Care

Shared decision making is a collaborative decision-making process between health care providers and patients or their surrogates, taking into account the best scientific evidence available while considering the patient's values, goals, and preferences. Decision aids are tools enabling SDM. This article discusses shared decision making in general and in the intensive care unit in particular and facilitators and barriers for the creation and implementation of International Patient Decision Aids Standards Collaboration-compliant decision aids for the intensive care unit and neuro-intensive care unit.

What Families Need and Physicians Deliver: Contrasting Communication Preferences Between Surrogate Decision-Makers and Physicians During Outcome Prognostication in Critically Ill TBI Patients

BACKGROUND

Surrogate decision-makers ("surrogates") and physicians of incapacitated patients have different views of prognosis and how it should be communicated, but this has not been investigated in neurocritically ill patients. We examined surrogates' communication preferences and physicians' practices during the outcome prognostication for critically ill traumatic brain injury (ciTBI) patients in two level-1 trauma centers and seven academic medical centers in the USA.

METHODS

We used qualitative content analysis and descriptive statistics of transcribed interviews to identify themes in surrogates (n = 16) and physicians (n = 20).

RESULTS

The majority of surrogates (82%) preferred numeric estimates describing the patient's prognosis, as they felt it would increase prognostic certainty, and limit the uncertainty perceived as frustrating. Conversely, 75% of the physicians reported intentionally omitting numeric estimates during prognostication meetings due to low confidence in family members' abilities to appropriately interpret probabilities, worry about creating false hope, and distrust in the accuracy and data quality of existing TBI outcome models. Physicians felt that these models are for research only and should not be applied to individual patients. Surrogates valued compassion during prognostication discussions, and acceptance of their goals-of-care decision by clinicians. Physicians and surrogates agreed on avoiding false hope.

CONCLUSION

We identified fundamental differences in the communication preferences of prognostic information between ciTBI patient surrogates and physicians. These findings inform the content of a future decision aid for goals-of-care discussions in ciTBI patients. If validated, these findings may have important implications for improving communication practices in the neurointensive care unit independent of whether a formal decision aid is used.

Shared Decision Making in Neurocritical Care

Shared decision making is a collaborative decision-making process between health care providers and patients or their surrogates, taking into account the best scientific evidence available while considering the patient's values, goals, and preferences. Decision aids are tools enabling SDM. This article discusses shared decision making in general and in the intensive care unit in particular and facilitators and barriers for the creation and implementation of International Patient Decision Aids Standards Collaboration-compliant decision aids for the intensive care unit and neuro-intensive care unit.

A Randomized Trial of a Family-Support Intervention in Intensive Care Units

BACKGROUND

Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients' preferences.

METHODS

We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates' mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates' mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay.

RESULTS

A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates' mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P=0.49). The surrogates' mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001).

CONCLUSIONS

Among critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates' burden of psychological symptoms, but the surrogates' ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care. (Funded by the UPMC Health System and the Greenwall Foundation; PARTNER ClinicalTrials.gov number, NCT01844492 .).

A Descriptive Study of Decision-Making Conversations during Pediatric Intensive Care Unit Family Conferences

BACKGROUND

Little is known about how decision-making conversations occur during pediatric intensive care unit (PICU) family conferences (FCs).

OBJECTIVE

Describe the decision-making process and implementation of shared decision making (SDM) during PICU FCs.

DESIGN

Observational study.

SETTING/SUBJECTS

University-based tertiary care PICU, including 31 parents and 94 PICU healthcare professionals involved in FCs.

MEASUREMENTS

We recorded, transcribed, and analyzed 14 PICU FCs involving decision-making discussions. We used a modified grounded theory and content analysis approach to explore the use of traditionally described stages of decision making (DM) (information exchange, deliberation, and determining a plan). We also identified the presence or absence of predefined SDM elements.

RESULTS

DM involved the following modified stages: information exchange; information-oriented deliberation; plan-oriented deliberation; and determining a plan. Conversations progressed through stages in a nonlinear manner. For the main decision discussed, all conferences included a presentation of the clinical issues, treatment alternatives, and uncertainty. A minority of FCs included assessing the family's understanding (21%), assessing the family's need for input from others (28%), exploring the family's desired decision-making role (35%), and eliciting the family's opinion (42%).

CONCLUSIONS

In the FCs studied, we found that DM is a nonlinear process. We also found that several SDM elements that could provide information about parents' perspectives and needs did not always occur, identifying areas for process improvement.

Ethical challenges in resuscitation

PURPOSE

A rapidly evolving resuscitation science provides more effective treatments to an aging population with multiple comorbidites. Concurrently, emergency care has become patient-centered. This review aims to describe challenges associated with the application of key principles of bioethics in resuscitation and post-resuscitation care; propose actions to address these challenges; and highlight the need for evidence-based ethics and consensus on ethical principles interpretation.

METHODS

Following agreement on the article's outline, subgroups of 2-3 authors provided narrative reviews of ethical issues concerning autonomy and honesty, beneficence/nonmaleficence and dignity, justice, specific practices/circumstances such as family presence during resuscitation, and emergency research. Proposals for addressing ethical challenges were also offered.

RESULTS

Respect for patient autonomy can be realized through honest provision of information, shared decision-making, and advance directives/care planning. Essential prerequisites comprise public and specific healthcare professionals' education, appropriate regulatory provisions, and allocation of adequate resources. Regarding beneficence/nonmaleficence, resuscitation should benefit patients, while avoiding harm from futile interventions; pertinent practice should be based on neurological prognostication and patient/family-reported outcomes. Regarding dignity, aggressive life-sustaining treatments against patients preferences should be avoided. Contrary to the principle of justice, resuscitation quality may be affected by race/income status, age, ethnicity, comorbidity, and location (urban versus rural or country-specific/region-specific). Current evidence supports family presence during resuscitation. Regarding emergency research, autonomy should be respected without hindering scientific progress; furthermore, transparency of research conduct should be promoted and funding increased.

CONCLUSIONS

Major ethical challenges in resuscitation science need to be addressed through complex/resource-demanding interventions. Such actions require support by ongoing/future research.

Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study

OBJECTIVE

To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission.

STUDY DESIGN

Prospective multicenter study.

SETTING

Eleven ICUs.

PATIENTS

All patients who died and/or had limitations on life support after ICU admission during a four-month period.

VARIABLES

Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission.

RESULTS

3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5).

CONCLUSION

Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.

How acceptable is paternalism? A survey-based study of clinician and nonclinician opinions on paternalistic decision making

We conducted an empirical study to explore clinician and lay opinions on the acceptability of physician paternalism. Respondents read a vignette describing a patient with brain hemorrhage facing urgent surgery that would be lifesaving but would result in long-term severe disability. Cases were randomized to show either low or high surrogate distress and certain or uncertain prognosis, with respondents rating the acceptability of not offering brain surgery. Clinicians (N = 169) were more likely than nonclinicians (N = 649) to find the doctor withholding surgery acceptable (30.2% vs. 11.4%, p ≤ 0.001). Among clinicians, the doctor withholding surgery was more acceptable when prognosis was certain to be poor (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.04, 4.01). There was no effect of surrogate distress on clinician ratings. Responses among lay public were more variable. Given the differences in attitudes across clinicians and lay public, there is an ongoing need to engage stakeholders in the process of end-of-life decision making.