Reconceptualizing How to Support Surrogates Making Medical Decisions for Critically Ill Patients

[Recommendations for time-limited trial in neurocritical care]

Many acute brain disorders are associated with acute disorders of consciousness. In an emergency situation, life-saving measures are usually taken first and intensive care is initiated. If there is no significant improvement with recovery of consciousness in the first few days, very complex decision-making situations arise regularly. In neurointensive care, a time-limited therapy trial (TLT) is an important structuring element in treatment planning and communication, as a binding agreement between the treatment team and the patient or legal representative on a treatment concept for a defined period of time. Due to the prolonged neurological rehabilitation phase, the TLT in neurointensive care can also last weeks or months. This often requires interdepartmental communication (acute/rehabilitation/long-term care), re-evaluation and implementation in neurointensive care. The recommendations include the definition, empirical evidence and implementation suggestions for a TLT for critically ill neurointensive care patients.

Decisions in end-of-life care: perspectives from family caregivers

BACKGROUND

Making healthcare decisions on behalf of loved ones can be highly stressful for family members to act as surrogate decision makers, especially when decisions are relevant to terminal care.

AIM

To understand the challenges that caregivers face when making decisions for family members at the end of life.

METHODS

A descriptive phenomenological approach using semi-structured interviews with seven family caregivers recruited from two palliative care institutions in Amman.

RESULTS

Family caregivers mentioned several reasons to avoid participating in decisions near their relative's end-of-life, such as holding on to hope that their family member would recover and fearing loss. Others expressed that they felt their relationship to the patient impaired their ability to make reliable judgments and they found it hard to know what the right decisions were. They were worried about being held responsible for the result of decisions and were concerned about felling guilty.

CONCLUSION

To conclude, caregivers do not feel prepared to make decisions about their relative's care and feel that they are too emotional and attached to the patient, or are afraid of the consequences of their decisions.

Predictors of ICU Surrogates' States of Concurrent Prolonged Grief, Posttraumatic Stress, and Depression Symptoms

OBJECTIVES

Scarce research explores factors of concurrent psychologic distress (prolonged grief disorder [PGD], posttraumatic stress disorder [PTSD], and depression). This study models surrogates' longitudinal, heterogenous grief-related reactions and multidimensional risk factors drawing from the integrative framework of predictors for bereavement outcomes (intrapersonal, interpersonal, bereavement-related, and death-circumstance factors), emphasizing clinical modifiability.

DESIGN

Prospective cohort study.

SETTING

Medical ICUs of two Taiwanese medical centers.

SUBJECTS

Two hundred eighty-eight family surrogates.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Factors associated with four previously identified PGD-PTSD-depressive-symptom states (resilient, subthreshold depression-dominant, PGD-dominant, and PGD-PTSD-depression concurrent) were examined by multinomial logistic regression modeling (resilient state as reference). Intrapersonal: Prior use of mood medications correlated with the subthreshold depression-dominant state. Financial hardship and emergency department visits correlated with the PGD-PTSD-depression concurrent state. Higher anxiety symptoms correlated with the three more profound psychologic-distress states (adjusted odds ratio [95% CI] = 1.781 [1.562-2.031] to 2.768 [2.288-3.347]). Interpersonal: Better perceived social support was associated with the subthreshold depression-dominant state. Bereavement-related: Spousal loss correlated with the PGD-dominant state. Death circumstances: Provision of palliative care (8.750 [1.603-47.768]) was associated with the PGD-PTSD-depression concurrent state. Surrogate-perceived quality of patient dying and death as poor-to-uncertain (4.063 [1.531-10.784]) correlated with the subthreshold depression-dominant state, poor-to-uncertain (12.833 [1.231-133.775]), and worst (12.820 [1.806-91.013]) correlated with the PGD-PTSD-depression concurrent state. Modifiable social-worker involvement (0.004 [0.001-0.097]) and a do-not-resuscitate order issued before death (0.177 [0.032-0.978]) were negatively associated with the PGD-PTSD-depression concurrent and the subthreshold depression-dominant state, respectively. Apparent unmodifiable buffering factors included surrogates' higher educational attainment, married status, and longer time since loss.

CONCLUSIONS

Surrogates' concurrent bereavement distress was positively associated with clinically modifiable factors: poor quality dying and death, higher surrogate anxiety, and palliative care-commonly provided late in the terminal-illness trajectory worldwide. Social-worker involvement and a do-not-resuscitate order appeared to mitigate risk.

Racial Differences in Shared Decision-Making About Critical Illness

Importance

Shared decision-making is the preferred method for evaluating complex tradeoffs in the care of patients with critical illness. However, it remains unknown whether critical care clinicians engage diverse patients and caregivers equitably in shared decision-making.

Objective

To compare critical care clinicians' approaches to shared decision-making in recorded conversations with Black and White caregivers of patients with critical illness.

Design, Setting, and Participants

This thematic analysis consisted of unstructured clinician-caregiver meetings audio-recorded during a randomized clinical trial of a decision aid about prolonged mechanical ventilation at 13 intensive care units in the US. Participants in meetings included critical care clinicians and Black or White caregivers of patients who underwent mechanical ventilation. The codebook included components of shared decision-making and known mechanisms of racial disparities in clinical communication. Analysts were blinded to caregiver race during coding. Patterns within and across racial groups were evaluated to identify themes. Data analysis was conducted between August 2021 and April 2023.

Main Outcomes and Measures

The main outcomes were themes describing clinician behaviors varying by self-reported race of the caregivers.

Results

The overall sample comprised 20 Black and 19 White caregivers for a total of 39 audio-recorded meetings with clinicians. The duration of meetings was similar for both Black and White caregivers (mean [SD], 23.9 [13.7] minutes vs 22.1 [11.2] minutes, respectively). Both Black and White caregivers were generally middle-aged (mean [SD] age, 47.6 [9.9] years vs 51.9 [8.8] years, respectively), female (15 [75.0%] vs 14 [73.7%], respectively), and possessed a high level of self-assessed health literacy, which was scored from 3 to 15 with lower scores indicating increasing health literacy (mean [SD], 5.8 [2.3] vs 5.3 [2.0], respectively). Clinicians conducting meetings with Black and White caregivers were generally young (mean [SD] age, 38.8 [6.6] years vs 37.9 [8.2] years, respectively), male (13 [72.2%] vs 12 [70.6%], respectively), and White (14 [77.8%] vs 17 [100%], respectively). Four variations in clinicians' shared decision-making behaviors by caregiver race were identified: (1) providing limited emotional support for Black caregivers, (2) failing to acknowledge trust and gratitude expressed by Black caregivers, (3) sharing limited medical information with Black caregivers, and (4) challenging Black caregivers' preferences for restorative care. These themes encompass both relational and informational aspects of shared decision-making.

Conclusions and Relevance

The results of this thematic analysis showed that critical care clinicians missed opportunities to acknowledge emotions and value the knowledge of Black caregivers compared with White caregivers. These findings may inform future clinician-level interventions aimed at promoting equitable shared decision-making.

Factors Associated With Family Surrogate Decisional-Regret Trajectories

CONTEXT/OBJECTIVES

The scarce research on factors associated with surrogate decisional regret overlooks longitudinal, heterogenous decisional-regret experiences and fractionally examines factors from the three decision-process framework stages: decision antecedents, decision-making process, and decision outcomes. This study aimed to fill these knowledge gaps by focusing on factors modifiable by high-quality end-of-life (EOL) care.

METHODS

This observational study used a prior cohort of 377 family surrogates of terminal-cancer patients to examine factors associated with their membership in the four preidentified distinct decisional-regret trajectories: resilient, delayed-recovery, late-emerging, and increasing-prolonged trajectories from EOL-care decision making through the first two bereavement years by multinomial logistic regression modeling using the resilient trajectory as reference.

RESULTS

Decision antecedent factors: Financial sufficiency and heavier caregiving burden increased odds for the delayed-recovery trajectory. Spousal loss, higher perceived social support during an EOL-care decision, and more postloss depressive symptoms increased odds for the late-emerging trajectory. More pre- and postloss depressive symptoms increased odds for the increasing-prolonged trajectory. Decision-making process factors: Making an anticancer treatment decision and higher decision conflict increased odds for the delayed-recovery and increasing-prolonged trajectories. Making a life-sustaining-treatment decision increased membership in the three more profound trajectories. Decision outcome factors: Greater surrogate appraisal of quality of dying and death lowered odds for the three more profound trajectories. Patient receipt of anticancer or life-sustaining treatments increased odds for the late-emerging trajectory.

CONCLUSION

Surrogate membership in decisional-regret trajectories was associated with decision antecedent, decision-making process, and decision outcome factors. Effective interventions should target identified modifiable factors to address surrogate decisional regret.

Family caregiver roles and challenges in assisting patients with cancer treatment decision-making: Analysis of data from a national survey

BACKGROUND

We aimed to describe the roles and challenges of family caregivers involved in patients' cancer treatment decision-making.

METHODS

Family caregiver-reported data were analyzed from a national survey conducted in the United States by CancerCare® (2/2021-7/2021). Four select-all-that-apply caregiver roles were explored: (1) observer (patient as primary decision-maker); (2) primary decision-maker; (3) shared decision-maker with patient and (4) decision delegated to healthcare team. Roles were compared across five treatment decisions: where to get treatment, the treatment plan, second opinions, beginning treatment and stopping treatment. Ten challenges faced by caregivers (e.g., information, cost, treatment understanding) were then examined. χ2 and regression analyses were used to assess associations between roles, decision areas, challenges and caregiver sociodemographics.

RESULTS

Of 2703 caregiver respondents, 87.6% reported involvement in patient decisions about cancer treatment, including 1661 who responded to a subsection further detailing their roles and challenges with specific treatment decisions. Amongst these 1661 caregivers, 22.2% reported an observing role, 21.3% a primary decision-making role, 53.9% a shared decision-making role and 18.1% a role delegating decisions to the healthcare team. Most caregivers (60.4%) faced ≥1 challenge, the most frequent being not knowing how treatments would affect the patient's physical condition (24.8%) and quality of life (23.2%). In multivariable models, being Hispanic/Latino/a was the strongest predictor of facing at least one challenge (b = -0.581, Wald = 10.69, p < .01).

CONCLUSIONS

Most caregivers were involved in patients' cancer treatment decisions. The major challenge was not understanding how treatments would impact patients' physical health and quality of life. Challenges may be more commonly faced by Hispanic/Latino/a caregivers.

PATIENT OR PUBLIC CONTRIBUTION

The CancerCare® survey was developed in partnership with caregiving services and research experts to describe the role of cancer family caregivers in patient decision-making and assess their needs for support. All survey items were reviewed by a CancerCare advisory board that included five professional patient advocates and piloted by a CancerCare social worker and other staff who provide counselling to cancer caregivers.

Surgeon-Patient Cross∼Talk: How It Happens, How to Fix It

Surgeon-patient communication is fraught with difficulties. Cross∼talk can be conceptualized as surgeons and patients speaking different languages, working out of different cerebral hemispheres. While as surgeons we principally function from our left brains, our patients are universally working from their right hemisphere, because the situation they find themselves in is new and overshadowed by extreme existential angst. Respecting patient autonomy is best done by shared decision-making, in which we attempt to bridge into the patient's right brain, openly exploring, and helping crystalize their values through a deliberative method that utilizes collaborative pushback. This approach is preferable to trying to drag them into our left-brained "fix it" mental model by informing them of the location in our well-worn surgical algorithm and asking them to choose between treatment options. Surrogates are under extreme psychosociospiritual duress, which can overwhelm and blunt their left-brained cognitive processing abilities (organizing information in working memory, evaluating options, and processing advice). However, this challenge can be overcome with empathy and by explaining the benefits and practice of substituted judgment during each family meeting. Whenever possible, the Palliative Triangle-surgeon, patient, family-should be established and executed preoperatively in high-stakes surgical scenarios to mitigate distress and prevent nonbeneficial value-incongruent over-treatment.

Decisional-Regret Trajectories From End-of-Life Decision Making Through Bereavement

CONTEXT

Regret plays a central role in surrogate decision making. Research on decisional regret in family surrogates is scarce and lacks longitudinal studies to illustrate the heterogenous, dynamic evolution of decisional regret.

OBJECTIVES

To identify distinct decisional-regret trajectories from end-of-life (EOL) decision making through the first two bereavement years among surrogates of cancer patients.

METHODS

A prospective, longitudinal, observational study was conducted on a convenience sample of 377 surrogates of terminally ill cancer patients. Decisional regret was measured by the five-item Decision Regret Scale monthly during the patient's last six months and 1, 3, 6, 13, 18, and 24 months post loss. Decisional-regret trajectories were identified using latent-class growth analysis.

RESULTS

Surrogates reported substantially high decisional regret (pre- and postloss mean [SD] as 32.20 [11.47] and 29.90 [12.47], respectively). Four decisional-regret trajectories were identified. The resilient trajectory (prevalence: 25.6%) showed a general low decisional-regret level with mild and transient perturbations around the time of patient death only. Decisional regret for the delayed-recovery trajectory (56.3%) accelerated before the patient's death and decreased slowly throughout bereavement. Surrogates in the late-emerging (10.2%) trajectory reported a low decisional-regret level before loss but their decisional regret increased gradually thereafter. The increasing-prolonged trajectory (6.9%) rapidly increased in decisional-regret levels during EOL decision making, peaked one-month post loss, then declined steadily but without a complete resolution.

CONCLUSION

Surrogates heterogeneously suffered decisional regret from EOL decision making through bereavement as evident by four identified distinct decisional-regret trajectories. Early identification and prevention of increasing/prolonged decisional-regret trajectories is warranted.

How symptoms of prolonged grief disorder, posttraumatic stress disorder, and depression relate to each other for grieving ICU families during the first two years of bereavement

Background

Bereaved ICU family surrogates are at risk of comorbid prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. Knowledge about temporal relationships between PGD, PTSD, and depression is limited by a lack of relevant studies and diverse or inappropriate assessment time frames given the duration criterion for PGD. We aimed to determine the temporal reciprocal relationships between PGD, PTSD, and depressive symptoms among ICU decedents’ family surrogates during their first 2 bereavement years with an assessment time frame reflecting the PGD duration criterion.

Methods

This prospective, longitudinal, observational study examined PGD, PTSD, and depressive symptoms among 303 family surrogates of ICU decedents from two academic hospitals using 11 items of the Prolonged Grief Disorder-13, the Impact of Event Scale—Revised, and the depression subscale of the Hospital Anxiety and Depression Scale, respectively, at 6, 13, 18, and 24 months post-loss. Cross-lagged panel modeling was conducted: autoregressive coefficients indicate variable stability, and cross-lagged coefficients indicate the strength of reciprocal relationships among variables between time points.

Results

Symptoms (autoregressive coefficients) of PGD (0.570–0.673), PTSD (0.375–0.687), and depression (0.591–0.655) were stable over time. Cross-lagged standardized coefficients showed that depressive symptoms measured at 6 months post-loss predicted subsequent symptoms of PGD (0.146) and PTSD (0.208) at 13 months post-loss. PGD symptoms did not predict depressive symptoms. PTSD symptoms predicted subsequent depressive symptoms in the second bereavement year (0.175–0.278). PGD symptoms consistently predicted subsequent PTSD symptoms in the first 2 bereavement years (0.180–0.263), whereas PTSD symptoms predicted subsequent PGD symptoms in the second bereavement year only (0.190–0.214). PGD and PTSD symptoms are bidirectionally related in the second bereavement year.

Conclusions

PGD, PTSD, and depressive symptoms can persist for 2 bereavement years. Higher PGD symptoms at 6 months post-loss contributed to the exacerbation of PTSD symptoms over time, whereas long-lasting PTSD symptoms were associated with prolonged depression and PGD symptoms beyond the first bereavement year. Identification and alleviation of depression and PGD symptoms as early as 6 months post-loss enables bereaved surrogates to grieve effectively and avoid the evolution of those symptoms into long-lasting PGD, PTSD, and depression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04216-5.

Pilot Randomized Clinical Trial of a Goals-of-Care Decision Aid for Surrogates of Patients With Severe Acute Brain Injury

BACKGROUND AND OBJECTIVES

Breakdowns in clinician-family communication in neurologic intensive care units (neuroICUs) are common, particularly for goals-of-care decisions to continue or withdraw life-sustaining treatments while considering long-term prognoses. Shared decision-making interventions (decision aids [DAs]) may prevent this problem and increase patient-centered care, yet none are currently available. We assessed the feasibility, acceptability, and perceived usefulness of a DA for goals-of-care communication with surrogate decision makers for critically ill patients with severe acute brain injury (SABI) after hemispheric acute ischemic stroke, intracerebral hemorrhage, or traumatic brain injury.

METHODS

We conducted a parallel-arm, unblinded, patient-level randomized, controlled pilot trial at 2 tertiary care US neuroICUs and randomized surrogate participants 1:1 to a tailored paper-based DA provided to surrogates before clinician-family goals-of-care meetings or usual care (no intervention before clinician-family meetings). The primary outcomes were feasibility of deploying the DA (recruitment, participation, and retention), acceptability, and perceived usefulness of the DA among surrogates. Exploratory outcomes included outcome of surrogate goals-of-care decision, code status changes during admission, patients' 3-month functional outcome, and surrogates' 3-month validated psychological outcomes.

RESULTS

We approached 83 surrogates of 58 patients and enrolled 66 surrogates of 41 patients (80% consent rate). Of 66 surrogates, 45 remained in the study at 3 months (68% retention). Of the 33 surrogates randomized to intervention, 27 were able to receive the DA, and 25 subsequently read the DA (93% participation). Eighty-two percent rated the DA's acceptability as good or excellent (median acceptability score 2 [IQR 2-3]); 96% found it useful for goals-of-care decision making. In the DA group, there was a trend toward fewer comfort care decisions (27% vs 56%, p = 0.1) and fewer code status changes (no change, 73% vs 44%, p = 0.02). At 3 months, fewer patients in the DA group had died (33% vs 69%, p = 0.05; median Glasgow Outcome Scale 3 vs1, p = 0.05). Regardless of intervention, 3-month psychological outcomes were significantly worse among surrogates who had chosen continuation of care.

DISCUSSION

A goals-of-care DA to support ICU shared decision making for patients with SABI is feasible to deploy and well perceived by surrogates. A larger trial is feasible to conduct, although surrogates who select continuation of care deserve additional psychosocial support.

CLINICAL TRIALS REGISTRATION

Clinicaltrials.gov NCT03833375.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that the use of a DA explaining the goals-of-care decision and the treatment options is acceptable and useful to surrogates of incapacitated critically ill patients with ischemic stroke, intracerebral hemorrhage, or traumatic brain injury.

Surrogate and Physician Decision Making for Mechanically Ventilated Patients According to Expected Patient Outcome

Background: Surrogates and physicians may differ in their priorities and perspectives when making decisions for incapacitated, critically ill patients. Objectives: To determine the extent to which surrogate and physician decisions to sustain life support are associated with their expectations for patient outcomes. Setting/Subjects: Surrogates and physicians of 100 mechanically ventilated patients at an academic, tertiary care medical center in the United States were surveyed. Measurements: Linear regression was used to determine if participant expectations for patient survival, good quality of life, and confidence in these expectations were associated with their agreement that mechanical ventilation should be continued if required for patient survival. Results: Surrogates were more likely than physicians to expect that patients would be alive in three months (91% interquartile range [IQR 70-95%] vs. 65% [IQR 43-77%], p < 0.001) and have good quality of life in three months (71% [IQR 50-90%] vs. 40% [IQR 19-50%], p < 0.001). Surrogates who were most confident in their prognostic abilities were also the most optimistic for good patient outcomes. As such, expectations for patient survival and good quality of life were not associated with level agreement that mechanical ventilation should be continued among confident surrogates, (R² = 0.03, p = 0.13) and (R² = 0.01, p = 0.53), respectively. In contrast, among physicians, confidence was not synonymous with optimism. Instead, the significant associations between expectations for patient survival and good quality of life with the agreement that mechanical ventilation should be continued were strengthened when physicians were confident, (R² = 0.34, p < 0.01) and (R² = 0.47, p < 0.001), respectively. Conclusion: Surrogates and physicians have different approaches to incorporating their expectations for patient prognosis and their confidence in these expectations when they are making decisions for incapacitated critically ill patients.

The neuroethics of disorders of consciousness: a brief history of evolving ideas

Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically responsible care in this domain are especially timely given recent surges in critically ill patients with prolonged disorders of consciousness associated with coronavirus disease 2019 around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery and ethical issues that arise within the context of caring for people with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.

Parents Are the Experts: A Qualitative Study of the Experiences of Parents of Children With Severe Neurological Impairment During Decision-Making

CONTEXT

Parents of children with severe neurologic impairment (SNI) often face high-stakes medical decisions when their child is hospitalized. These decisions involve technology and/or surgery, goals of care and/or advance care planning, or transitions of care.

OBJECTIVES

This study describes the experiences of parents of children with SNI during decision-making.

METHODS

Eligible participants were parents facing a decision for a child with SNI admitted to acute or intensive care units at a single tertiary pediatric center. Parents completed 1:1 semi-structured interviews and brief surveys between August 2019 and February 2020. Demographic information was extracted from the child's electronic health record. A team of palliative and complex care researchers with expertise in qualitative methods used thematic content analysis to formulate results.

RESULTS

25 parents participated. The majority had children with congenital/chromosomal SNI conditions (n = 13, 65%), >5 subspecialists (n = 14, 61%), and chronic technology assistance (n = 25, 100%). 68% (n = 17) were mothers and 100% identified as being their child's primary decision-maker. Responses from parents included 3 major themes: 1) our roles and actions; 2) our stresses and challenges; and 3) our meaning and purpose. Responses highlighted the pervasiveness of parental decision-making efforts and parents' advocacy and vigilance regarding their child's needs. Despite this, parents often felt unheard and undervalued in the hospital.

CONCLUSION

During hospitalizations, when parents of children with SNI often face high-stakes medical decisions, interventions are needed to support parents and ensure they feel heard and valued as they navigate their child's medical needs and system challenges.

Actionable processes of care important to patients and family who experienced a prolonged intensive care unit stay: Qualitative interview study

AIM

To use positive deviance to identify actionable processes of care that may improve outcomes and experience from the perspectives of prolonged intensive care unit (ICU) stay survivors and family members.

DESIGN

Prospective qualitative interview study in two geographically distant settings: Canada (2018/19) and the United Kingdom (2019/20).

METHODS

Patient and family participant inclusion criteria comprised: aged over 18 years, ICU stay in last 2 years of over 7 days, able to recall ICU stay and provided informed consent. We conducted semi-structured in-person or telephone interviews. Data were analysed using a positive deviance approach.

RESULTS

We recruited 29 participants (15 Canadian; 14 UK). Of these, 11 were survivors of prolonged ICU stay and 18 family members. We identified 22 actionable processes (16 common to Canadian and UK participants, 4 Canadian only and 2 UK only). We grouped processes under three themes: physical and functional recovery (nine processes), patient psychological well-being (seven processes) and family relations (six processes). Most commonly identified physical/functional processes were regular physiotherapy, and fundamental hygiene and elimination care. For patient psychological well-being: normalizing the environment and routines, and alleviating boredom and loneliness. For family relations: proactive communication, flexible family visiting and presence with facilities for family. Our positive deviance analysis approach revealed that incorporation of these actionable processes into clinical practice was the exception as opposed to the norm perceived driven by individual acts of kindness and empathy as opposed to standardized processes.

CONCLUSION

Actionable processes of care important to prolonged ICU stay survivors and family members differ from those frequently used in ICU quality improvement (QI) tools.

IMPACT

Our study emphasizes the need to develop QI tools that standardize delivery of actionable processes important to patients and families experiencing a prolonged ICU stay. As the largest healthcare professional group, nurses can play an essential role in leading this.

Associations of death-preparedness states with bereavement outcomes for family caregivers of terminally ill cancer patients

OBJECTIVE

Death preparedness involves cognitive prognostic awareness and emotional acceptance of a relative's death. Effects of retrospectively assessed cognitive prognostic awareness and emotional preparedness for patient death have been individually investigated among bereaved family caregivers. We aimed to prospectively examine associations of caregivers' death-preparedness states, determined by conjoint cognitive prognostic awareness and emotional preparedness for death, with bereavement outcomes.

METHODS

Associations of caregivers' death-preparedness states (no-death-preparedness, cognitive-death-preparedness-only, emotional-death-preparedness-only, and sufficient-death-preparedness states) at last preloss assessment with bereavement outcomes over the first two bereavement years were evaluated among 332 caregivers of advanced cancer patients using hierarchical linear models with the logit-transformed posterior probability for each death-preparedness state.

RESULTS

Caregivers with a higher logit-transformed posterior probability for sufficient death-preparedness state reported less prolonged-grief symptoms, lower likelihoods of severe depressive symptoms and heightened decisional regret, and better mental health-related quality of life (HRQOL). Caregivers with a higher logit-transformed posterior probability for no-death-preparedness state reported less prolonged-grief symptoms, a lower likelihood of severe depressive symptoms, and better mental HRQOL. A higher logit-transformed posterior probability for cognitive-death-preparedness-only state was associated with bereaved caregivers' higher likelihood of heightened decisional regret, whereas that for emotional-death-preparedness-only state was not associated with caregivers' bereavement outcomes.

CONCLUSIONS

Caregivers' bereavement outcomes were associated with their preloss death-preparedness states, except for physical health-related QOL. Interventions focused on not only cultivating caregivers' accurate prognostic awareness but also adequately preparing them emotionally for their relative's forthcoming death are actionable opportunities for high-quality end-of-life care and are urgently warranted to facilitate caregivers' bereavement adjustment.

Elternzentrierte ethische Entscheidungsfindung für Frühgeborene im Grenzbereich der Lebensfähigkeit – Reflexion über die Bedeutung probabilistischer Prognosen als Entscheidungsgrundlage

Frühgeborene im Grenzbereich der Lebensfähigkeit befinden sich in einer prognostischen Grauzone. Das bedeutet, dass deren Prognose zwar schlecht, aber nicht hoffnungslos ist, woraus folgt, dass nach Geburt lebenserhaltende Behandlungen nicht obligatorisch sind. Die Entscheidung für oder gegen lebenserhaltende Maßnahmen ist wertbeladen und für alle Beteiligten enorm herausfordernd. Sie sollte eine zwischen Eltern und Ärzt*innen geteilte Entscheidung sein, wobei sie unbedingt mit den Präferenzen der Eltern abgestimmt sein sollte. Bei der pränatalen Beratung der Eltern legen die behandelnden Ärzt*innen üblicherweise numerische Schätzungen der Prognose vor und nehmen in der Regel an, dass die Eltern ihre Behandlungspräferenzen davon ableiten. Inwieweit probabilistische Daten die Entscheidungen der Eltern in prognostischen Grauzonen tatsächlich beeinflussen, ist noch unzureichend untersucht. In der hier vorliegenden Arbeit wird eine Studie reflektiert, in welcher die Hypothese geprüft wurde, dass numerisch bessere oder schlechtere kindliche Prognosen die Präferenzen werdender Mütter für lebenserhaltende Maßnahmen nicht beeinflussen. In dieser Studie zeigte sich, dass die elterlichen Behandlungspräferenzen eher von individuellen Einstellungen und Werten als von Überlegungen zu numerischen Ergebnisschätzungen herzurühren scheinen. Unser Verständnis, welche Informationen werdende Eltern, die mit einer extremen Frühgeburt konfrontiert sind, wünschen und brauchen, ist noch immer unvollständig. Bedeutende medizinische Entscheidungen werden keineswegs nur rational und prognoseorientiert gefällt. In der vorliegenden Arbeit wird diskutiert, welchen Einfluss der Prozess der Entscheidungsfindung auf das Beratungsergebnis haben kann und welche Implikationen sich aus den bisher vorliegenden Studienergebnissen ergeben – klinisch-praktisch, ethisch und wissenschaftlich.