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

A Randomized Trial of Shared Decision-Making in Code Status Discussions

BACKGROUND

The effect of a shared decision-making approach on patients' code status decisions remains unknown. We compared an approach for shared decision-making with usual care to evaluate the effect on patients' code status preferences and quality of decision-making.

METHODS

In a pragmatic cluster-randomized controlled trial conducted in six teaching hospitals in Switzerland, we randomly assigned residents to conduct code status discussions based on either an approach incorporating didactic teaching, observation, and feedback and a shared decision-making checklist with a decision aid, or usual care. The primary end point was patients choosing a do-not-resuscitate (DNR) code status in the event of a cardiac arrest. The key secondary end point was patients' decisional uncertainty, measured by the Decisional Conflict Scale (range 0 to 100, with lower scores indicating lower decisional uncertainty).

RESULTS

A total of 206 residents caring for 2663 medical patients were included in the trial. Compared with patients in the usual care group, patients in the intervention group had a significantly higher frequency of choosing DNR as their code status (685/1370 (50.0%) vs. 481/1293 (37.2%); adjusted risk ratio, 1.37 (95% confidence interval, 1.25 to 1.50); P<0.001). The intervention was associated with lower decisional uncertainty (Decisional Conflict Scale score, 14.4±15.3 vs. 21.8±20.2 points; adjusted difference, -7.06 (95% confidence interval, -9.43 to -4.68).

CONCLUSIONS

An approach for shared decision-making that included the discussion of expected outcomes had a significant influence on the code status of medical patients, with a higher preference for DNR code status, and was associated with less uncertainty around the decision. (Funded by the Swiss National Science Foundation and the Swiss Society of General Internal Medicine; ClinicalTrials.gov number, NCT03872154.).

Continuation of Potentially Inappropriate Life-Sustaining Therapies: Provider Perspectives

CONTEXT

Prior work examines provider perspectives on withholding potentially inappropriate life-sustaining treatments over family objections; however, data are limited regarding how physicians approach situations in which they are considering withholding or withdrawing life-sustaining therapies against the wishes of the patient's family.

OBJECTIVES

This study sought to better understand the way in which pediatric critical care clinicians navigate situations in which families request life-sustaining therapies that the team feels may be inappropriate.

METHODS

We conducted a series of semi-structured group interviews with pediatric critical care faculty and used these data to create a case-based, ten-question ethical dilemma survey, which was disseminated nationally to pediatric intensivists. This paper explores participant responses to survey question three, which presented a case in which family requests continuation of ventilatory/nutritional support after severe traumatic brain injury with minimal recovery potential.

RESULTS

Most participants reported that they would offer the requested interventions; however, there was substantial variation among participants regarding the best next steps. Participants who chose to submit free-text responses described thoughtfully attempting to balance avoiding prolongation of suffering and respecting parents' roles as decision-makers for their child.

CONCLUSIONS

The variation between participants in their approach to this ethical dilemma underscores its difficulty, as well as the importance of institutional support structures (e.g. ethics, legal, risk management, palliative care). In a healthcare system with limited resources to support families taking care of critically ill and technology-dependent children, our study underscores a need for training, practice, and institutional support for physicians assisting families in navigating these decisions.

Enhancing shared decision-making for infants in the intensive care unit: lessons from parents

BACKGROUND

Understanding parent preferences and experiences of decision-making can guide interventions to improve shared decision-making. We aimed to characterize how parents (1) incorporated values into decision-making, (2) evaluated clinician recommendations, and (3) experienced their decisional role.

METHODS

In this qualitative study, we longitudinally interviewed parents of infants with neurologic conditions about their experiences making decisions for their child. Infants were eligible if they were (1) hospitalized in a critical care unit, (2) < 1 years old, (3) diagnosed with a neurologic condition and (4) expected to have a family conference to discuss goals of care or neurologic prognosis. Data were analyzed using a conventional content analysis approach.

RESULTS

In total, 123 interviews were conducted with 52 parents (n = 37 mothers, n = 15 fathers) of 37 infants. We identified 3 themes: (1) Clarifying and communicating values: Parents characterized challenges weighing multiple decision-relevant values. (2) Evaluating clinician recommendations: Parents appreciated clinician recommendations that incorporated their values. (3) Understanding decision-making roles: Parents typically preferred an active role; poor alignment between preferred and actual decision-making role sometimes precipitated conflict with the team.

CONCLUSION

We identified parent-informed opportunities to support shared decision-making for critically ill infants. Future interventions should target strategies to help parents clarify and communicate values, ensure that clinician recommendations acknowledge parent values, and identify parent-preferred decisional roles.

IMPACT

Existing data suggest gaps in how parents and clinicians partner in making decisions for critically ill infants. In this descriptive qualitative study, we characterized the parent experience of decision-making amidst critical illness. Parents shared challenges associated with weighing and communicating multiple, sometimes competing, decision-relevant values. Parents appreciated when clinicians offered recommendations that acknowledged their values. Parents preferred an active decision-making role; poor alignment between preferred and actual decision-making role sometimes led to conflict with the team. Future decision-making interventions should target strategies to help parents communicate and clarify values, ensure that clinician recommendations integrate parent values, and identify parent-preferred decisional roles.

Clinician use of 'worry' statements during surrogate decision making in the hospital

OBJECTIVE

Current guidance of how to share a prognosis with patients or surrogate decision makers suggests the use of "I worry" statements. Despite this guidance, there is little known about how "worry" or "concern" statements are used in clinical settings. The purpose of this analysis was to examine the function of "worry" statements in clinician-surrogate decision-making conversations with life-or-death implications.

METHODS

We audio recorded 27 clinician-surrogate conversations in two hospitals in one Midwest city in the USA. We used conversation analysis, a qualitative method, to analyze clinicians' use of "worry" statements throughout the corpus and what course of action they were "doing" in the interaction.

RESULTS

There were two distinct uses of "worry" statements. Clinicians' use of "worry" statements to convey the gravity of the patient's situation of a poor prognosis seemed to forecast an introduction to limiting treatment as a potential option. When discussing treatment, "worry" statements seemed to have a persuasive function against pursuing treatment. Surrogates often resisted "worry" statements in the discussion of treatment, as these statements conveyed restricting choices that surrogates have the authority to make.

CONCLUSION

The balance of the clinician's epistemic authority of the medical understanding of the patient's situation with the surrogate's authority in making a decision is worthy of further exploration.

PRACTICE IMPLICATIONS

Surrogate resistance to "worry" statements in the discussion of treatment may be more a function of the persuasion to limit treatment than the "worry" statements themselves. Further research is necessary to determine best practice language during treatment deliberation.

Outcome Predictions at Two Time Points among Surrogates and Physicians of Mechanically Ventilated Patients

OBJECTIVES

The decisions surrogates and physicians make for incapacitated critically ill patients depend in part on their expectations for patient recovery. We sought to determine whether the accuracy of surrogate and physician outcome predictions made during the ICU stay improves over time.

DESIGN

Survey study.

SETTING

Academic Medical Center.

SUBJECTS

Surrogates and physicians of 100 mechanically ventilated patients from March 2018 to April 2019.

INTERVENTIONS

At the end of the first week of mechanical ventilation and 1 week later, participants indicated on visual analog scales (0-100%) expectations that the patient would require mechanical ventilation in 1 month, require artificial nutrition in 1 month, be alive in 3 months, and be living at home in 3 months. Patient status was determined at 1 and 3 months.

MEASUREMENTS AND MAIN RESULTS

Area under the receiver operating characteristic curves (AUROCs) were determined for each outcome, at each time point. Patients who died within the first month were considered to require mechanical ventilation and artificial nutrition in the primary analysis. AUROCs for initial surrogate predictions were 0.61 (95% CI, 0.50-0.72) for mechanical ventilation, 0.67 (95% CI, 0.56-0.78) for artificial nutrition, 0.66 (95% CI, 0.55-0.7) for survival, and 0.61 (95% CI, 0.50-0.73) for living at home. AUROCs for initial physician predictions were 0.60 (95% CI, 0.49-0.71) for mechanical ventilation, 0.72 (95% CI, 0.61-0.0.83) for artificial nutrition, 0.69 (95% CI, 0.59-0.80) for survival, and 0.76 (95% CI, 0.66-0.85) for living at home. Average expectations among surrogates and physicians were highly stable over time; adjustments made to expectations did not result in more accurate predictions for the measured outcomes (p > 0.05).

CONCLUSIONS

Among surrogates and physicians of patients who were mechanically ventilated for 1 week, outcome predictions were better than would be expected by chance and not significantly improved 1 week later.

Nudging Clinicians to Promote Serious Illness Communication for Critically Ill Patients: A Pragmatic Cluster Randomized Trial

Importance

Guidelines recommend that intensive care unit (ICU) clinicians consider prognosis and offer a comfort-focused treatment alternative to patients with limited prognoses to promote preference-sensitive treatment decisions.

Objective

To determine whether nudging ICU clinicians to adhere to communication guidelines improves outcomes among critically ill patients at high risk of death or severe functional impairment.

Design, Setting, and Participants

This 4-arm pragmatic, stepped-wedge, cluster randomized trial (conducted February 1, 2018-October 31, 2020, follow-up through April 29, 2021, and analyses December 2023-January 2024) involved 3500 encounters of adults with chronic serious illness receiving mechanical ventilation for at least 48 hours at 10 hospitals comprising 17 medical, surgical, specialty, or mixed ICUs in community, rural, and urban settings.

Interventions

Two clinician-directed electronic health record nudge interventions were each compared with usual care alone and combined: document of 6-month functional prognosis and whether a comfort-focused treatment alternative was offered or a reason why not.

Main Outcomes and Measures

The primary outcome was hospital length of stay, with death coded at the 99th percentile. Secondary end points included 22 measures of acute care utilization, end-of-life care processes, and mortality.

Results

Of 3500 patient encounters among 3250 patients (mean [SD] age, 63.2 [13.5] years; 46.1% female), 3384 encounters (96.7%) had complete baseline data and were included in risk-adjusted analyses. The overall intervention document completion rate for all patients was 75.0% (n = 1714) and similar across groups. Among the 3500 encounters, observed hospital mortality was 35.7% (n = 1249), and the median observed length of stay was 8.93 days (IQR, 4.64-16.23). The median length of stay with deaths coded as the 99th percentile did not differ between any intervention and usual care groups (for length of stay, all adjusted median difference 95% CIs include 0; for hospital mortality, all adjusted risk difference [RD] 95% CIs include 0). Results were similar in sensitivity analyses with death coded as low at the fifth percentile and without ranking deaths. Compared with usual care, a higher percentage of patients were discharged to hospice in the treatment alternative group (10.9% vs 7.3%; adjusted RD, 6% [95% CI, 1%-10%]) and the combined group (8.9% vs 7.3%; adjusted RD, 6% [95% CI, 0%-12%]). The treatment alternative intervention led to earlier comfort-care orders (3.6 vs 4.5 days; adjusted hazard ratio, 1.42 [95% CI, 1.06-1.92]). The 20 other secondary end points were unaffected by the interventions.

Conclusions and Relevance

This cluster randomized clinical trial found that electronically nudging ICU clinicians to adhere to communication guidelines was feasible but did not reduce hospital length of stay.

Trial Registration

ClinicalTrials.gov Identifier: NCT03139838.

Electronic Health Records and Family Satisfaction in the ICU: Communication, Care Processes, and Decision-Making

Objectives: To evaluate electronic health records and explore associations with the satisfaction of families of critically ill patients. Methods: Exploratory cohort study. Included 94 patients with severe chronic illnesses or chronic critical illness who were admitted to the ICU and their family members. Family satisfaction was assessed using the Family Satisfaction ICU (FS-ICU 24) questionnaire, through the FS-ICU Care score (perception of care itself), FS-ICU Decision Making score (perception of decision-making), and FS-ICU Total score, and queried about the use of a room suitable for communication. Electronic health records were analyzed for elements of communication with family members, care processes, and decision-making. Results: The scores were FS-ICU Care 91.1 (76.8-98.0), FS-ICU DM 90.0 (77.5-97.5), and FS-ICU total 90.7 (78.0-97.0). In 17 (18.1%) of the medical records, there was a documented family meeting within the first 72 hours, and in 9.6%, there was documentation of communication about functionality, wishes and values, and consultation for palliative care. The use of a suitable room for communication was reported as "never" or "rarely" by 45 (47.8%) of the family members. There was a trend towards greater satisfaction with social support and lower satisfaction among family members of deceased patients, with 9 (25.8%) of these family members feeling that the patient was uncomfortable before death, and the records of meetings and communication of poor prognosis were associated with a lower perception of discomfort (P < .05). Conclusions: The satisfaction of family members of critically ill patients was high and was not significantly associated with the documentation deficiencies found. Deficiencies in communication appear to have influenced the perception of family members. Various perspectives are necessary for analyzing the care provided to patients and families in the ICU.

Characterizing Physician Recommendations within Code Status Documentation: A Multicentre Cohort Study and Qualitative Discourse Analysis

BACKGROUND

Discussion of patients' treatment preferences for cardiopulmonary resuscitation is routine practice for adults admitted to hospital. Ideally, these "code status discussions" provide an opportunity to ensure patients receive care that is concordant with their values and priorities. The degree of physician recommendations that occur during these discussions is unknown.

OBJECTIVE

This study sought to characterize physician treatment recommendations during code status discussions in older hospitalized medical patients.

DESIGN, PARTICIPANTS, AND APPROACH

We conducted a retrospective cohort study of 200 patients, 75 years or older, admitted to the general medical service in one of four hospitals in Toronto, Canada. Medical records were reviewed to abstract documentation by physicians that referenced a code status discussion. We used qualitative discourse analysis to characterize the nature of these documented code status discussions, with a focus on physician treatment recommendations.

KEY RESULTS

The majority of recommendations involved de-escalation or avoidance of invasive treatments. The strength of recommendations ranged from a passive physician role of providing advice, where the ultimate decision was deferred to the patient/surrogate, to an active role of explicitly not offering interventions, which involved informed non-dissent. Physicians often documented a brief rationale for specific recommendations, either focused on their estimation that the patient had a poor prognosis or their interpretation of the patient's goals and priorities. However, there was a paucity of documentation supporting how physicians determined these interpretations. Some physicians used the term "quality of life" to imply that invasive life-sustaining treatments were unlikely to benefit the patient.

CONCLUSIONS

We uncovered a range of physician practices in providing recommendations during code status discussions. While the strength and rationale varied, physicians often failed to document patients' goals and priorities when making treatment recommendations. These findings highlight an opportunity to improve how physicians formulate, communicate, and document their recommendations around code status.

Unique considerations in the assessment and management of traumatic brain injury in older adults

The age-specific incidence of traumatic brain injury in older adults is rising in high-income countries, mainly due to an increase in the incidence of falls. The severity of traumatic brain injury in older adults can be underestimated because of a delay in the development of mass effect and symptoms of intracranial haemorrhage. Management and rehabilitation in older adults must consider comorbidities and frailty, the treatment of pre-existing disorders, the reduced potential for recovery, the likelihood of cognitive decline, and the avoidance of future falls. Older age is associated with worse outcomes after traumatic brain injury, but premorbid health is an important predictor and good outcomes are achievable. Although prognostication is uncertain, unsubstantiated nihilism (eg, early withdrawal decisions from the assumption that old age necessarily leads to poor outcomes) should be avoided. The absence of management recommendations for older adults highlights the need for stronger evidence to enhance prognostication. In the meantime, decision making should be multidisciplinary, transparent, personalised, and inclusive of patients and relatives.

Perspectives of Clinicians on the Value of the Get to Know Me Board in the ICU

BACKGROUND

Critical illness can render patients at heightened risk of anonymity, loss of dignity, and dehumanization. Because dehumanization results in significant patient distress, it is imperative to find ways to humanize care in the ICU. A Get to Know Me board (GTKMB) is a personal patient profile designed to bring the patient from anonymity; however, its widespread adoption has been challenging.

RESEARCH QUESTION

Identify perspectives of ICU clinicians on the value of the GTKMB in caring for patients in the ICU.

STUDY DESIGN AND METHODS

This qualitative study used focus groups conducted via videoconference. We recruited stakeholders from multiprofessional teams across different ICU settings at a large US quaternary care center. Thematic content analysis approach was performed to identify key themes and concepts.

RESULTS

We interviewed 38 participants in six focus groups including 10 nurses, seven physicians, six advanced practice providers, five rehabilitation therapists, a respiratory therapist, and a social worker. Themes highlighted the role of the GTKMB in multiple domains including humanizing care of the critically ill, fostering communication, connecting with families, and guiding and facilitating care processes. Several subthemes were identified for each category.

INTERPRETATION

The GTKMB was considered important in fostering humanized caring in the ICU by diverse members of an interprofessional ICU team, helping to facilitate communication, establish family connection, and guide care.

Development of web- and mobile-based shared decision-making tools in the neurological intensive care unit

In the neurological intensive care unit (neuroICU), patients with severe acute brain injury (SABI) are rendered unable to make their own healthcare decisions. The responsibility of making life-or-death decisions, such as goals of care, is carried by surrogate decision-makers, usually families. In addition to the burden of decision-making, the emotional burden on families is further compounded by prognostication uncertainty, time-pressure for decision-making, and difficulties in understanding and interpreting the patient's values and preferences, ultimately resulting in potential clinician-family communication breakdown. Despite these challenges, there is currently no guidance on how to best approach these difficult decisions. Shared decision-making (SDM) has emerged as the recommended approach to improve clinician-family communication, empowering surrogates to take an active role in decision-making by providing a structured framework for information exchange, deliberation, and treatment decisions. Decision aids (DAs) facilitate SDM by offering balanced, accessible, unbiased information and helping surrogates decide according to patients' values. This review highlights the potential advantage of digital over paper-based DAs, including improved accessibility, interactivity, and personalization, and the integration of emerging technologies to enhance DA effectiveness. Additionally, we review the current digital DAs developed for the neuroICU setting.

Intractable conflicts over end-of-life decisions: A descriptive and ethical analysis of French case-law

CONTEXT

In European and Anglo-Saxon countries, life-sustaining treatment (LST) limitation decisions precede more than 80% of ICU deaths. However, there is now increasing evidence of disagreement and conflict between clinical teams and family members over LST limitation decisions. In some cases, these conflicts are brought to the courts. The aim of this study was to provide a descriptive and qualitative analysis of cases brought to the French courts.

METHODS

We conducted a retrospective national observational study. All identified cases of emergency recourse to the judge in the context of LST limitation decisions in France between 2005 and 2022 were included.

RESULTS

Seventy-six cases were investigated by the judge, with an increasing number over the years. The LST limitation decisions contested by the relatives were mainly decisions to withdraw treatment (78%) concerning patients with neurological injury (76%). The judge successively assessed the compliance with the legal decision-making process and the characterization of the inappropriateness of treatments. The latter was assessed by the judge using medical and non-medical criteria. In all, the medical decision was upheld in 29 cases (38%) and over-ruled in 20 cases (26%). Thirteen cases (17%) were finally settled out of court, and 14 patients (18%) died before the end of the investigation. The qualitative analysis highlighted opposing moral values and principles put forward by family members and physicians.

CONCLUSION

The growing incidence and deeply intertwined elements of these conflicts call for more policy and research to resolve them before they go to court.

Emerging ethical issues in patients with disorders of consciousness: A clinical guide

Clinicians who manage patients with disorders of consciousness (DoC) commonly encounter challenging ethical issues. Consciousness disorders include the vegetative state, the minimally conscious state, and covert consciousness resulting from cognitive-motor dissociation. The practice landscape of ethical issues encompasses making the correct diagnosis; making and communicating an accurate prognosis despite irreducible uncertainty; conducting effective shared decision-making with a lawful surrogate decision-maker to deliver goal-concordant care; providing optimal medical, rehabilitative, and palliative care across the spectrum of care sites: acute inpatient, neurorehabilitative, chronic, and palliative; respecting the human rights of and advocating for DoC patient, an historically under-served population and, when appropriate, properly participating in decisions to withhold or withdraw life-sustaining therapy. Research and translational issues in DoC patients include the challenges posed by emerging diagnostics and therapeutics and their prudential integration into clinical practice in the service of patients and their families. Our conceptual analysis of these ethical issues and our practical advice to address them comprise the subject material of this chapter.

[S3 Guideline: Treating Chronic Respiratory Failure with Non-invasive Ventilation]

The S3 guideline on non-invasive ventilation as a treatment for chronic respiratory failure was published on the website of the Association of the Scientific Medical Societies in Germany (AWMF) in July 2024. It offers comprehensive recommendations for the treatment of chronic respiratory failure in various underlying conditions, such as COPD, thoraco-restrictive diseases, obesity-hypoventilation syndrome, and neuromuscular diseases. An important innovation is the separation of the previous S2k guideline dating back to 2017, which included both invasive and non-invasive ventilation therapy. Due to increased scientific evidence and a significant rise in the number of affected patients, these distinct forms of therapy are now addressed separately in two different guidelines.The aim of the guideline is to improve the treatment of patients with chronic respiratory insufficiency using non-invasive ventilation and to make the indications and therapy recommendations accessible to all involved in the treatment process. It is based on the latest scientific evidence and replaces the previous guideline. This revised guideline provides detailed recommendations on the application of non-invasive ventilation, ventilation settings, and the subsequent follow-up of treatment.In addition to the updated evidence, important new features of this S3 guideline include new recommendations on patient care and numerous detailed treatment pathways that make the guideline more user-friendly. Furthermore, a completely revised section is dedicated to ethical issues and offers recommendations for end-of-life care. This guideline is an important tool for physicians and other healthcare professionals to optimize the care of patients with chronic respiratory failure. This version of the guideline is valid for three years, until July 2027.

Current Status of and Barriers to Primary Palliative Care Recognized by Critical Care Specialist Nurses: A Nationwide Cross-Sectional Questionnaire Survey in Japan

Objectives: To investigate the current state of primary palliative care practice in Japanese critical care settings, identify care perceived as equivalent to primary palliative care, and explore the barriers. Methods: We employed a quantitative descriptive questionnaire survey with a nationwide cross-sectional design involving 740 critical care specialist nurses. Results: Questionnaires were received from 384 nurses, yielding a response rate of 51.9%. Nurses recognized typical palliative care provided to cancer patients, such as "relieving suffering at end-of-life" (95.3%), "pain management" (88.8%), and "caring for patients' psychological suffering" (88.3%), as primary palliative care in the critical care setting. They also recognized "monitoring and management of delirium" (68.5%), "caring for patients' social suffering" (63.5%), and "preventing post-intensive care syndromes" (61.7%) less frequently as aspects of primary palliative care in critical care settings. Additionally, the recognition was lower among emergency department nurses than intensive care unit nurses. The nurses recognized inadequate overall palliative care practices, especially regarding patients' social (72.1%) and spiritual (76.8%) suffering. They recognized "insufficient knowledge and skills among critical care medical staff" (70.6%) and "unable to confirm the patients' preferences to treatment goals" (54.4%) as barriers to providing primary palliative care. The barriers that nurses recognized less often were "uncertainty about palliative care in critical care settings" (6.8%) and "disagreements among nursing teams regarding providing palliative care" (8.3%). Conclusion: Specialist nurses understood palliative care but felt unprepared in primary palliative care due to limited knowledge. Improved education in primary palliative care and patient-family communication is needed in Japan's critical care settings.

The Mediating Effect of Perceived Social Support and Health Literacy on the Relationship Between Decisional Dilemma and Participation in Shared Decision-Making Among Chinese Parents of Premature Infants

PURPOSE

This research was conducted to explore the mediating effect of perceived social support and health literacy on the relationship between decisional dilemmas and participation in shared decision-making among Chinese parents of premature infants.

DESIGN AND METHODS

This cross-sectional study recruited 225 Chinese parents of premature infants in a neonatal ward of a Chinese hospital through convenience sampling. Data were collected from August 2022 to February 2023 using 5 self-administered instruments. Structural equation modeling and multiple mediation tests were applied to explore the interplay among perceived social support, health literacy, decisional dilemmas, and participation in shared decision-making. The study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

RESULTS

Decisional dilemmas were found to negatively impact participation in shared decision-making. Perceived social support and health literacy were identified as partial mediators in this relationship, collectively accounting for a mediation effect of -0.413, which represents 50.0% of the total effect.

CONCLUSION

The findings elucidate a multifaceted model of factors influencing participation in shared decision-making among Chinese parents of premature infants. Prompt recognition of these variables can enable nursing professionals to incorporate tailored management strategies within patient-centered care frameworks, thereby enhancing decisional outcomes.

Identifying Decisional Needs for Adult Tracheostomy and Prolonged Mechanical Ventilation Decision Making to Inform Shared Decision-Making Interventions

BACKGROUND

Decision making for adult tracheostomy and prolonged mechanical ventilation is emotionally complex. Expectations of surrogate decision makers and physicians rarely align. Little is known about what surrogates need to make goal-concordant decisions. Currently, little is known about the decisional needs of surrogates and providers, impeding efforts to improve the decision-making process.

METHODS

Using a thematic analysis approach, we performed a qualitative study with semistructured interviews with surrogates of adult patients receiving mechanical ventilation (MV) being considered for tracheostomy and physicians routinely caring for patients receiving MV. Recruitment was stopped when thematic saturation was reached. We describe the decision-making process, identify core decisional needs, and map the process and needs for possible elements of a future shared decision-making tool.

RESULTS

Forty-three participants (23 surrogates and 20 physicians) completed interviews. Hope, Lack of Knowledge Data, and Uncertainty emerged as the 3 main themes that described the decision-making process and were interconnected with one another and, at times, opposed each other. Core decisional needs included information about patient wishes, past activity/medical history, short- and long-term outcomes, and meaningful recovery. The themes were the lens through which the decisional needs were weighed. Decision making existed as a balance between surrogate emotions and understanding and physician recommendations.

CONCLUSIONS

Tracheostomy and prolonged MV decision making is complex. Hope and Uncertainty were conceptual themes that often battled with one another. Lack of Knowledge & Data plagued both surrogates and physicians. Multiple tangible factors were identified that affected surrogate decision making and physician recommendations.

IMPLICATIONS

Understanding this complex decision-making process has the potential to improve the information provided to surrogates and, potentially, increase the goal-concordant care and alignment of surrogate and physician expectations.

HIGHLIGHTS

Decision making for tracheostomy and prolonged mechanical ventilation is a complex interactive process between surrogate decision makers and providers.Qualitative themes of Hope, Uncertainty, and Lack of Knowledge & Data shared by both providers and surrogates were identified and described the decision-making process.Concrete decisional needs of patient wishes, past activity/medical history, short- and long-term outcomes, and meaningful recovery affected each of the larger themes and represented key information from which surrogates and providers based decisions and recommendations.The qualitative themes and decisional needs identified provide a roadmap to design a shared decision-making intervention to improve adult tracheostomy and prolonged mechanical ventilation decision making.

Supporting parents' emotional and mental health in the antenatal consultation

Supporting parents' emotional and mental health is crucial during antenatal consultations, in which expectant parents often receive serious news about their infant and sometimes face complex antenatal or postnatal decision-making. Being considerate of the circumstances to mitigate barriers and stressors, utilizing clear and sensitive language, and personalizing counseling and decision-making to support parents' pluralistic values are strategies that individual neonatologists can use to promote parents' mental wellness in these encounters. Partnership with clinicians of other disciplines and professions in antenatal consultations can help in providing additional medical information and parent support; however, care must be coordinated within the team to ensure that confusing or conflicting counseling is avoided. In addition to improving communication skills for these encounters as individuals and teams, opportunities also exist to enhance support of parents' mental health at the institutional and national level.

Complex Decision-Making in Paediatric Intensive Care: A Discussion Paper and Suggested Model

Paediatric Intensive Care Units (PICU) are complex interdisciplinary environments where challenging, high stakes decisions are frequently encountered. We assert that appropriate decisions are more likely to be made if the decision-making process is comprehensive, reasoned, and grounded in thoughtful deliberation. Strategies to overcome barriers to high quality decision-making including, cognitive and implicit bias, group think, inadequate information gathering, and poor quality deliberation should be incorporated. Several general frameworks for decision-making exist, but specific guidance is scarce. In this paper, we provide specific guidance on collaborative complex decision-making for PICUs. The proposed approach is on principles of procedural justice and pragmatic hermeneutics. The process encompasses set-up/planning, information gathering, question formulation, analysis (perspectives, values, and principles), action plan development, decision documentation, and a review and appeal mechanism. The process can be adapted to suit other clinical contexts. Research evaluating the process, exploring how best to develop education for clinicians, and how to build a culture that values high quality deliberation, is worthwhile.

[Ethical boundary decisions in intensive care medicine]

BACKGROUND

Ethical decision-making is a cornerstone of intensive care and emergency medicine. In acute scenarios, clinicians often face rapid, high-stakes decisions concerning life and death, made more challenging by time constraints and incomplete information. These decisions are further complicated by economic constraints, limited resources, and evolving technological capabilities.

QUESTION

What decision-making aids and factors can be employed in ethical borderline cases within intensive care medicine?

RESULTS

Fundamental ethical principles such as patient autonomy, beneficence, non-maleficence, and justice form the basis for medical treatment decisions. Evaluating the patient's will through advanced directives or proxy consensus is crucial, although advanced directives can be ambiguous. Assessing quality of life is increasingly important, with instruments such as the Clinical Frailty Scale (CFS) being utilized. For older patients, a holistic approach is recommended, focusing on overall health rather than chronological age. In patients with advanced underlying diseases, a multidisciplinary dialogue is essential.

DISCUSSION

Decision-making in intensive care medicine requires careful consideration of medical, ethical, and individual factors. Despite advances in artificial intelligence and prognostic models, human judgment remains crucial. During periods of resource scarcity, ethically sound triage protocols are required. The challenge lies in applying these principles and factors in clinical practice while respecting the individuality of each patient.

Advance care planning in patients with respiratory failure

Advance care planning (ACP) is a complex and iterative communication process between patients, surrogates and clinicians that defines goals of care that may include, but is not limited to, documentation of advance directives. The aim of ACP is to promote patient-centred care tailored to the patient's clinical situation through informed preparation for the future and improved communication between patient, clinicians and surrogates, if the latter need to make decisions on patient's behalf.The aim of this article is to review research related to ACP in acute and chronic respiratory failure, regarding the process, communication, shared decision-making, implementation and outcomes.Research has produced controversial results on ACP interventions due to the heterogeneity of measures and outcomes, but positive outcomes have been described regarding the quality of patient-physician communication, preference for comfort care, decisional conflict and patient-caregiver congruence of preferences and improved documentation of ACP or advance directives.The main barriers to ACP in chronic respiratory failure are the uncertainty of prognosis (particularly in the organ failure trajectory), the choice of the best timing for initiation and the lack of training of healthcare workers. In acute respiratory failure, the ACP process can be very short, should include the patient whenever possible, and is based on a discussion of treatments appropriate to the patient's functional status prior to the event (e.g. assessment of frailty) and clear communication of the likely consequences of possible options.All healthcare worker dealing with patients with serious illnesses should have training in communication skills to promote engagement in ACP discussions.

Shared Decision-Making Communication and Prognostic Misunderstanding in the ICU

Importance

Surrogate misunderstanding of patient survival prognosis in the intensive care unit (ICU) is associated with poor patient and surrogate outcomes. Shared decision-making (SDM) may reduce misunderstanding.

Objective

To evaluate the association between SDM-aligned communication and prognostic misunderstanding.

Design, Setting, and Participants

This retrospective cohort study was conducted at 13 medical and surgical ICUs at 5 hospitals in North Carolina, Pennsylvania, and Washington between December 2012 and January 2017. Participants were surrogates of adult patients receiving prolonged mechanical ventilation and ICU physicians. Analysis was performed May to November 2023.

Exposure

SDM-aligned communication during ICU family meetings, defined as the presence of high-quality serious illness communication behaviors aligned with SDM principles.

Main Outcomes and Measures

The primary outcome was postmeeting surrogate prognostic misunderstanding, defined as the absolute difference between the physician's estimate of survival prognosis and the surrogate's perception of that estimate (range, 0-100 percentage points). The secondary outcome was postmeeting physician misunderstanding, defined as the absolute difference between a surrogate's estimate of survival prognosis and the physician's perception of that estimate (range, 0-100 percentage points). Prognostic misunderstanding of 20 percentage points or greater was considered clinically significant as in prior work.

Results

Of 137 surrogates, most were female (102 [74.5%]), and there were 22 (16.1%) Black surrogates, 107 (78.1%) White surrogates, and 8 surrogates (5.8%) with other race and ethnicity. Of 100 physicians, most were male (64 [64.0%]), with 11 (11.0%) Asian physicians, 4 (4.0%) Black physicians, and 75 (75.0%) White physicians. Median (IQR) surrogate prognostic misunderstanding declined significantly after family meetings (before: 22.0 [10.0 to 40.0] percentage points; after: 15.0 [5.0 to 34.0] percentage points; P = .002), but there was no significant change in median (IQR) physician prognostic misunderstanding (before: 12.0 [5.0 to 30.0] percentage points; after: 15.0 [5.0 to 29.0] percentage points; P = .99). In adjusted analyses, SDM-aligned communication was not associated with prognostic misunderstanding among surrogates or physicians (surrogates: β = -0.74; 95% CI, -1.81 to 0.32; P = .17; physicians: β = -0.51; 95% CI, -1.63 to 0.62; P = .38). In a prespecified subgroup analysis of 78 surrogates (56.9%) with clinically significant premeeting prognostic misunderstanding, SDM-aligned communication was associated with reduced surrogate postmeeting prognostic misunderstanding (β = -1.71; 95% CI, -3.09 to -0.34; P = .01).

Conclusions and Relevance

In this retrospective cohort study, SDM-aligned communication was not associated with changes in prognostic misunderstanding for all surrogates or physicians, but it was associated with reduced prognostic misunderstanding among surrogates with clinically significant misunderstanding at baseline.

Barriers and Strategies to Effective Serious Illness Communication for Patients with End-Stage Liver Disease in the Intensive Care Setting

Background: Patients with end-stage liver disease (ESLD) often require Intensive Care Unit (ICU) admission during the disease trajectory, but aggressive medical treatment has not resulted in increased quality of life for patients or caregivers. Methods: This narrative review synthesizes relevant data thematically exploring the current state of serious illness communication in the ICU with identification of barriers and potential strategies to improve performance. We provide a conceptual model underscoring the importance of providing comprehensible disease and prognosis knowledge, eliciting patient values and aligning these values with available goals of care options through a series of discussions. Achieving effective serious illness communication supports the delivery of goal concordant care (care aligned with the patient's stated values) and improved quality of life. Results: General barriers to effective serious illness communication include lack of outpatient serious illness communication discussions; formalized provider training, literacy and culturally appropriate patient-directed serious illness communication tools; and unoptimized electronic health records. ESLD-specific barriers to effective serious illness communication include stigma, discussing the uncertainty of prognosis and provider discomfort with serious illness communication. Evidence-based strategies to address general barriers include using the Ask-Tell-Ask communication framework; clinician training to discuss patients' goals and expectations; PREPARE for Your Care literacy and culturally appropriate written and online tools for patients, caregivers, and clinicians; and standardization of documentation in the electronic health record. Evidence-based strategies to address ESLD-specific barriers include practicing with empathy; using the "Best-Case, Worst Case" prognostic framework; and developing interdisciplinary solutions in the ICU. Conclusion: Improving clinician training, providing patients and caregivers easy-to-understand communication tools, standardizing EHR documentation, and improving interdisciplinary communication, including palliative care, may increase goal concordant care and quality of life for critically ill patients with ESLD.

Shared Decision-making in Palliative and End-of-life Care in the Cardiac Intensive Care Unit

Patients and clinicians in the cardiac intensive care unit (CICU) are often tasked with making high-stakes decisions about aggressive or life- sustaining therapies. Shared decision-making (SDM), a collaborative process where patients and clinicians work together to make medical decisions that are aligned with a patient's goals and values, is therefore highly relevant in the CICU, especially in the context of palliative or end-of-life decisions. Despite its importance, there are barriers to optimal integration and implementation of SDM. This review describes the fundamentals and models of SDM, the role of SDM in the CICU, and evidence-based strategies to promote SDM in the CICU.

Neonatal Resuscitation and Delivery Room Care: A Changing Global Landscape

With 98% of neonatal deaths occurring in low- and middle-income countries (LMICs), leading health organizations continue to focus on global reduction of neonatal mortality. The presence of a skilled clinician at delivery has been shown to decrease mortality. However, there remain significant barriers to training and maintaining clinician skills and ensuring that facility-specific resources are consistently available to deliver the most essential, evidence-based newborn care. The dynamic nature of resource availability poses an additional challenge for essential newborn care educators in LMICs. With increasing access to advanced neonatal resuscitation interventions (ie, airway devices, code medications, umbilical line placement), the international health-care community is tasked to consider how to best implement these practices safely and effectively in lower-resourced settings. Current educational training programs do not provide specific instructions on how to scale these advanced neonatal resuscitation training components to match available materials, staff proficiency, and system infrastructure. Individual facilities are often faced with adapting content for their local context and capabilities. In this review, we discuss considerations surrounding curriculum adaptation to meet the needs of a rapidly changing landscape of resource availability in LMICs to ensure safety, equity, scalability, and sustainability.

Assessing palliative care practices in intensive care units and interpreting them using the lens of appropriate care concepts. An umbrella review

PURPOSE

Intensive care units (ICUs) have significant palliative care needs but lack a reliable care framework. This umbrella review addresses them by synthesising palliative care practices provided at end-of-life to critically ill patients and their families before, during, and after ICU admission.

METHODS

Seven databases were systematically searched for systematic reviews, and the umbrella review was conducted according to the guidelines laid out by the Joanna Briggs Institute (JBI).

RESULTS

Out of 3122 initial records identified, 40 systematic reviews were included in the synthesis. Six key themes were generated that reflect the palliative and end-of-life care practices in the ICUs and their outcomes. Effective communication and accurate prognostications enabled families to make informed decisions, cope with uncertainty, ease distress, and shorten ICU stays. Inter-team discussions and agreement on a plan are essential before discussing care goals. Recording care preferences prevents unnecessary end-of-life treatments. Exceptional end-of-life care should include symptom management, family support, hydration and nutrition optimisation, avoidance of unhelpful treatments, and bereavement support. Evaluating end-of-life care quality is critical and can be accomplished by seeking family feedback or conducting a survey.

CONCLUSION

This umbrella review encapsulates current palliative care practices in ICUs, influencing patient and family outcomes and providing insights into developing an appropriate care framework for critically ill patients needing end-of-life care and their families.

Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review

BACKGROUND

Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them.

AIM

The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies.

DESIGN

Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies.

METHODS

Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions.

RESULTS

Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity.

CONCLUSION

Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.

Limitations of life-sustaining therapies in South Africa

PURPOSE

Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA).

MATERIALS AND METHODS

This study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world.

RESULTS

LLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients' best-interest, with the need for an ICU bed only rarely considered.

CONCLUSIONS

Withholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.

Impact of a family support intervention on hospitalization costs and hospital readmissions among ICU patients at high risk of death or severe functional impairment

BACKGROUND

Patients with advanced critical illness often receive more intensive treatment than they would choose for themselves, which contributes to high health care costs near the end of life. The purpose of this study was to determine whether a family support intervention delivered by the interprofessional ICU team decreases hospitalization costs and hospital readmissions among critically ill patients at high risk of death or severe functional impairment.

RESULTS

We examined index hospitalization costs as well as post-discharge utilization of acute care hospitals, rehabilitation and skilled nursing facilities, and hospice services for the PARTNER trial, a multicenter, stepped-wedge, cluster randomized trial of an interprofessional ICU family support intervention. We determined patients' total controllable and direct variable costs using a computerized accounting system. We determined post-discharge resource utilization (as defined above) by structured telephone interview at 6-month follow-up. We used multiple variable regression modelling to compare outcomes between groups. Compared to usual care, the PARTNER intervention resulted in significantly lower total controllable costs (geometric mean: $26,529 vs $32,105; log-linear coefficient: - 0.30; 95% CI - 0.49, - 0.11) and direct variable costs ($3912 vs $6034; - 0.33; 95% CI - 0.56, - 0.10). A larger cost reduction occurred for decedents ($20,304 vs. $26,610; - 0.66; 95% CI - 1.01, - 0.31) compared to survivors ($31,353 vs. $35,015; - 0.15; 95% CI - 0.35,0.05). A lower proportion in the intervention arm were re-admitted to an acute care hospital (34.9% vs 45.1%; 0.66; 95% CI 0.56, 0.77) or skilled nursing facility (25.3% vs 31.6%; 0.63; 95% CI 0.47, 0.84).

CONCLUSIONS

A family support intervention delivered by the interprofessional ICU team significantly decreased index hospitalization costs and readmission rates over 6-month follow-up. Trial registration Trial registration number: NCT01844492.

Transition of Intensive Care Unit Patients and Their Families to Home After Acute Hospital Care

Patients in the intensive care unit (ICU) increasingly are expected to eventually return home after acute hospital care. Yet transitional care for ICU patients and their families is often delayed until the patient is about to be transferred to another location or level of care. Transitions theory is a middle-range nursing theory that aims to provide guidance for safe and effective nursing care and research while an individual experiences a transition. Intensive care unit nurses are well positioned to provide ICU transitional care planning early. This article applies the transitions theory as a theoretical model to guide the study of the transition to home after acute hospital care for ICU patients and their families. This theory application can help ICU nurses provide holistic patient- and family-centered transitional care to achieve optimal outcomes by addressing the predischarge and postdischarge needs of patients and families.

Advancing hypertensive disorders of pregnancy management: insights from the 5th preeclampsia scientific symposium in Ghana

The 5th Preeclampsia Scientific Symposium (PSS2023) organized by Action on Preeclampsia (APEC) Ghana was themed: 'Realign, Refocus: Improving outcomes of Hypertensive Disorders of Pregnancy through Shared Decision Making, Research & Quality of Care'. It took place on the 18th and 19th of May 2023 at the Ghana College of Physicians and Surgeons (GCPS), Accra Ghana. This transdisciplinary symposium brought together a national representation of experts, policy makers, scientists, and healthcare professionals to discuss key priorities, opportunities, approaches, and strategies to improve the maternal and perinatal outcomes of hypertensive disorders of pregnancy (HDP) in Ghana and the sub-region. The symposium centered around three key themes: realigning/refocusing patient-doctor decision making processes to improve outcomes of HDP; realigning/refocusing clinical care to improve outcomes of HDP; and leveraging on research to predict, recognize and manage high-risk women.This report summarizes insights from the diverse presentations and discussions held at the #PSS2023. This will form a roadmap for future research, policy, and interventions to improve outcomes of HDP in Ghana and the sub-region. The symposium provided a wealth of evidence and knowledge from various experts, highlighting the need for women-centered care, equitable re-allocation of resources, multi-sectoral and innovative approaches, capacity strengthening. Other highlights include knowledge base development and increased stakeholder and community engagement with an overall aim of improving outcomes of HDP. The symposium also fostered inclusivity, welcoming survivors of HDP and their families at a scientific platform. They provided invaluable insights into the challenges faced and the lived experiences of those affected by the disease. Trainees and students also benefited from the symposium as it provided networking opportunities with fellow researchers, and a front row to gaining insights into cutting-edge research in Ghana.

Generalized music therapy to reduce neuroactive drug needs in critically ill patients. Study protocol for a randomized trial

BACKGROUND

Critically ill patients are exposed to several physical and emotional stressors, needing analgesic and sedative drugs to tolerate invasive procedures and the harsh intensive care unit (ICU) environment. However, this pharmacological therapy presents several side effects: guidelines suggest using a light sedation target, keeping critically ill patients calm, conscious, and cooperative. Personalized music therapy (MT) can reduce stress and anxiety, decreasing the need for drugs. The aim of the current investigation is to compare different approaches for MT in the ICU: a personalized approach, with music selected by patients/families and listened through headphones, or a generalized approach, with ambient music chosen by a music therapist and transmitted through speakers.

PRIMARY OUTCOME

number of days "free from neuroactive drugs" in the first 28 days after ICU admission.

SECONDARY OUTCOMES

total amount of neuroactive drugs (midazolam, propofol, morphine, fentanyl, haloperidol), stress during ICU stay (sleep at night, anxiety and agitation, use of physical restraints, stressors evaluated at discharge), the feasibility of generalized MT (interruptions requested by staff members and patients/families).

METHODS

Randomized, controlled trial with three groups of critically ill adults: a control group, without MT; a personalized MT group, with music for at least 2 h per day; a generalized MT group, with music for 12.5 h/day, subdivided into fifteen 50-min periods.

DISCUSSION

One hundred fifty-three patients are expected to be enrolled. This publication presents the rationale and the study methods, particularly the strategies used to build the generalized MT playlist. From a preliminary analysis, generalized MT seems feasible in the ICU and is positively received by staff members, critically ill patients, and families.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03280329. September 12, 2017.

Prognostication in Neurocritical Care

OBJECTIVE

This article synthesizes the current literature on prognostication in neurocritical care, identifies existing challenges, and proposes future research directions to reduce variability and enhance scientific and patient-centered approaches to neuroprognostication.

LATEST DEVELOPMENTS

Patients with severe acute brain injury often lack the capacity to make their own medical decisions, leaving surrogate decision makers responsible for life-or-death choices. These decisions heavily rely on clinicians' prognostication, which is still considered an art because of the previous lack of specific guidelines. Consequently, there is significant variability in neuroprognostication practices. This article examines various aspects of neuroprognostication. It explores the cognitive approach to prognostication, highlights the use of statistical modeling such as Bayesian models and machine learning, emphasizes the importance of clinician-family communication during prognostic disclosures, and proposes shared decision making for more patient-centered care.

ESSENTIAL POINTS

This article identifies ongoing challenges in the field and emphasizes the need for future research to ameliorate variability in neuroprognostication. By focusing on scientific methodologies and patient-centered approaches, this research aims to provide guidance and tools that may enhance neuroprognostication in neurocritical care.

Decision-Making in Surgery

Surgeons face unique challenges in perioperative decision-making and communication with patients and families. In cardiothoracic surgery, the stakes are high, life and death decisions must be made quickly, and surgeons often lack a longstanding relationship with patients and families prior to intervention. This review considers specific challenges in the preoperative period followed by those faced postoperatively. While preoperative deliberation and informed consent focus on reaching a decision between 2 or more alternative approaches, the most vexing postoperative decisions often involve the patient's discontent with the best-case outcome or how to ensure goal-concordant care when complications arise. This review explores the preoperative ethical and legal requirement for informed consent by describing the contemporary preferred method, shared decision-making. We also present a framework to optimize surgeon communication and promote patient and family engagement in the setting of high-risk surgery for older patients with serious illness. In the postoperative period the family is often tasked with deciding what to do about major complications when the patient has lost decision-making capacity. We discuss several examples and offer strategies for surgeons to navigate these challenging situations. We also explore the concepts of clinical heroism and futility in relation to communicating with patients and families about the outcomes of surgery. Persistent ethical challenges in decision-making suggest that surgeons should improve their skills in communicating with patients to better engage with them, both before and after surgery.

Pediatricians' Perspectives on Introducing Transitional Care into Handover Between Pediatric Intensive Care Units and General Wards

Background

Despite the availability of a considerable number of studies on transitional care, few qualitative studies have synthesized physicians' perspectives on PICU-to-ward transition to develop a comprehensive transitional care curriculum. The aim of this study is to explore physicians' perceptions and management of the transition of critically ill children from the PICU to the general ward, with the aim of providing an evidence-based curriculum.

Methods

A qualitative study was conducted between July and August 2022. The study involved semi-structured interviews with 11 participants, and data analysis was carried out using NVivo 12.0 software through thematic analysis method.

Results

Based on the data analysis, three main themes were identified: recognition of professional roles during transition, difficulties during implementation transitional care and suggestions for improving transitional care.

Conclusion

The insights of doctors can be valuable in improving transitional care for critically ill children during PICU-to-Ward transition and in developing relevant curricula. It is essential to introduce standardized clinical pathways and strengthen curricula on critical elements, including communication and follow-up.

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.

Shared decision-making and its influencing factors among parents of children with cancer in China: A cross-sectional study

PURPOSE

This study aimed at exploring SDM implementation and its influencing factors, and preferences towards SDM among parents of children with cancer in China.

DESIGN AND METHODS

This cross-sectional study recruited 204 participants from 2 grade-A tertiary hospitals in Guangzhou, China. The preferences towards decision-making, the status of SDM were measured by CPS-P and SDM-Q-9. The nurse support were measure by NPST, the needs of parents were measured by Questionnaire for Needs of Parents Whose Children are in PICU, and sociodemographic and disease-related questionnaires were used to investigate general information of children and parents. Descriptive statistics, univariate analysis, and multivariable linear regression were used for data analysis.

RESULTS

Of 204 participants, about half of parents (55.4 %) tended to choose SDM, however, 40.2 % of them still show passive attitudes. The mean SDM-Q-9 score was 31.07 ± 8.74, and the result showed that age (β = 2.480, P＜0.05), relapse (β = 4.407, P＜0.01), course of disease (β = -5.213, P＜0.01), relationships with doctors (β = -4.05, P＜0.05), trust in doctors (β = -2.796, P＜0.05), and communication and information support from nurses (β = 0.651, P＜0.01) were the main factors influencing SDM for parents.

CONCLUSIONS

Over half of Chinese parents tended to choose SDM, but their real participation in SDM is unsatisfactory. Parents who were older, had good relationships with doctors, trusted in doctors, received more communication and information support from nurses, and whose children had shorter course of disease, suffered relapses, participated in SDM better.

How do Clinicians View the Process of Shared Decision-Making with Parents Facing Extremely Early Deliveries? Results from an Online Survey

OBJECTIVE

The objective of this study was to better understand how neonatology (Neo) and maternal-fetal medicine (MFM) physicians approach the process of shared decision-making (SDM) with parents facing extremely premature (<25 weeks estimated gestational age) delivery during antenatal counseling.

STUDY DESIGN

Attending physicians at U.S. centers with both Neo and MFM fellowships were invited to answer an original online survey about antenatal counseling for extremely early newborns. Preferences for conveying information are reported elsewhere. Here, we report clinicians' self-assessments of their ability to engage in deliberations and decision-making and perceptions of what is important to parents in the SDM process. Multivariable logistic regression analyzed respondents' views with respect to individual characteristics, such as specialty, gender, and years of clinical experience.

RESULTS

In total, 74 MFMs and 167 Neos representing 94% of the 81 centers surveyed responded. Neos versus MFMs reported repeat visits with parents less often (<0.001) and agreed that parents were more likely to have made delivery room decisions before they counseled them less often (p < 0.001). Respondents reported regularly achieving most goals of SDM, with the exception of providing spiritual support. Most respondents reported that spiritual and religious views, risk to an infant's survival, and the infant's quality of life were important to parental decision-making, while a physician's own personal choice and family political views were reported as less important. While many barriers to SDM exist, respondents rated language barriers and family views that differ from those of a provider as the most difficult barriers to overcome.

CONCLUSION

This study provides insights into how consultants from different specialties and demographic groups facilitate SDM, thereby informing future efforts for improving counseling and engaging in SDM with parents facing extremely early deliveries and supporting evidence-based training for these complex communication skills.

KEY POINTS

· Perceptions differed by specialty and demographics.. · Parents' spiritual needs were infrequently met.. · Barriers to shared decision-making exist..

Feasibility and Acceptability of a Novel Intensive Care Unit Communication Intervention ("Let's Talk") and Initial Assessment Using the Multiple Goals Theory of Communication

Background: Family members of intensive care unit (ICU) patients often report poor communication, feeling unprepared for ICU family meetings, and poor psychological outcomes after decision-making. The objective of this study was to create a tool to prepare families for ICU family meetings and assess feasibility of using Communication Quality Analysis (CQA) to measure communication quality of family meetings. Methods: This observational study was conducted at an academic tertiary care center in Hershey, PA from March 2019 to 2020. Phase 1a involved conceptual design. Phase 1b entailed acceptability testing of 2 versions of the tool (text-only, comic) with 9 family members of non-capacitated ICU patients; thematic analysis of semi-strucutred interviews was conducted. Phase 1c assessed feasibility of applying CQA to audio-recorded ICU family meetings (n = 17); 3 analysts used CQA to assess 6 domains of communication quality. Wilcoxon Signed Rank tests were used to interpret CQA scores. Results: Four themes emerged from Phase 1b interviews: participants 1) found the tool useful for meeting preparation and organizing thoughts, 2) appreciated emotional content, 3) preferred the comic form (67%), and 4) had indifferent or negative perceptions about specific elements. In Phase 1c, clinicians scored higher on the CQA content and engagement domains; family members scored higher on the emotion domain. CQA scores in the relationship and face domains had the lowest quality ratings. Conclusions: Let's Talk may help families become better prepared for ICU family meetings. CQA provides a feasible approach to assessing communication quality that identifies specific areas of strengths and weaknesses in communication.

Examining how goals of care communication are conducted between doctors and patients with severe acute illness in hospital settings: A realist systematic review

BACKGROUND

Patient involvement in goals of care decision-making has shown to enhance satisfaction, affective-cognitive outcomes, allocative efficiency, and reduce unwarranted clinical variation. However, the involvement of patients in goals of care planning within hospitals remains limited, particularly where mismatches in shared understanding between doctors and patients are present.

AIM

To identify and critically examine factors influencing goals of care conversations between doctors and patients during acute hospital illness.

DESIGN

Realist systematic review following the RAMESES standards. A protocol has been published in PROSPERO (CRD42021297410). The review utilised realist synthesis methodology, including a scoping literature search to generate initial theories, theory refinement through stakeholder consultation, and a systematic literature search to support program theory.

DATA SOURCES

Data were collected from Medline, PubMed, Embase, CINAHL, PsychINFO, Scopus databases (1946 to 14 July 2023), citation tracking, and Google Scholar. Open-Grey was utilized to identify relevant grey literature. Studies were selected based on relevance and rigor to support theory development.

RESULTS

Our analysis included 52 papers, supporting seven context-mechanism-output (CMO) hypotheses. Findings suggest that shared doctor-patient understanding relies on doctors being confident, competent, and personable to foster trusting relationships with patients. Low doctor confidence often leads to avoidance of discussions. Moreover, information provided to patients is often inconsistent, biased, procedure-focused, and lacks personalisation. Acute illness, medical jargon, poor health literacy, and high emotional states further hinder patient understanding.

CONCLUSIONS

Goals of care conversations in hospitals are nuanced and often suboptimal. To improve patient experiences and outcome of care interventions should be personalised and tailored to individual needs, emphasizing effective communication and trusting relationships among patients, families, doctors, and healthcare teams. Inclusion of caregivers and acknowledgment at the service level are crucial for achieving desired outcomes. Implications for policy, research, and clinical practice, including further training and skills development for doctors, are discussed.

Health Professional vs Layperson Values and Preferences on Scarce Resource Allocation

Importance

COVID-19 prompted rapid development of scarce resource allocation (SRA) policies to be implemented if demand eclipsed health systems' ability to provide critical care. While SRA policies follow general ethical frameworks, understanding priorities of those affected by policies and/or tasked with implementing them is critical.

Objective

To evaluate whether community members and health care profesionals (HCP) agree with SRA protocols at the University of California (UC).

Design, Setting, and Participants

This survey study used social media and community-partnered engagement to recruit participants to a web-based survey open to all participants aged older than 18 years who wished to enroll. This study was fielded between May and September 2020 and queried participants' values and preferences on draft SRA policy tenets. Participants were also encouraged to forward the survey to their networks for snowball sampling. Data were analyzed from July 2020 to January 2024.

Main Outcomes and Measures

Survey items assessed values and preferences, graded on Likert scales. Agreement was tabulated as difference in Likert points between expressed opinion and policy tenets. Descriptive statistics were tested for significance by HCP status. Free text responses were analyzed using applied rapid qualitative analysis.

Results

A total of 1545 participants aged older than 18 years (mean [SD] age 49 [16] years; 1149 female participants [74%], 478 health care practitioners [30%]) provided data on SRA values and preferences. Agreement with UC SRA policy as drafted was moderately high among respondents, ranging from 67% to 83% across domains. Higher agreement with the interim policy was observed for laypersons across all domains except health-related factors. HCPs agreed more strongly on average that resources should not be allocated to those less likely to survive (HCP mean, 3.70; 95% CI, 3.16-3.59; vs layperson mean, 3.38; 95% CI, 3.17-3.59; P = .002), and were more in favor of reallocating life support from patients less likely to those more likely to survive (HCP mean, 6.41; 95% CI, 6.15-6.67; vs layperson mean, 5.40; 95% CI, 5.23-5.58; P < .001). Transparency and trust building themes were common in free text responses and highly rated on scaled items.

Conclusions and Relevance

This survey of SRA policy values found moderate agreement with fundamental principles of such policies. Engagement with communities affected by SRA policy should continue in iterative refinement in preparation for future crises.

Family engagement in the care of infectious patients in intensive care units: A hybrid concept analysis

AIM

This study aims to define and investigate characteristics, antecedents, and consequences of the concept of family engagement in caring for patients with infectious diseases hospitalised in intensive care units.

DESIGN

This is a three-phase hybrid model study (theoretical, fieldwork, and analytical phase).

METHODS

The York University Guidelines were used in the theoretical phase, and ultimately, 16 pieces of literature related to the subject under study from 2011 to 2021 were reviewed. The content analysis was used for fieldwork phases; eight participants were interviewed. Then, the theoretical and fieldwork findings were compared, integrated, and analysed.

RESULTS

This concept has characteristics such as; awareness, belief, perception, and willingness of the nurse to engage the family; a sense of responsibility, willingness, and sacrifice of the family; the physical or virtual presence of the family; triangular interaction between the nurse, patient, and family; perception and identifying the goals; education and information transfer; team collaboration; delegation of responsibility to the family; decision making; and protection of the family. Antecedents include the availability of infrastructure; patient, family, and nurse conditions; and the quality implementation of engagement. The consequences include positive consequences related to the patient, family, nursing, and society, as well as some negative consequences. This study provided a comprehensive perception of family engagement in the care of patients with infectious diseases in intensive care units and defined it more clearly, showing its characteristics, antecedents, and consequences.

PATIENT OR PUBLIC CONTRIBUTION

Eight participants were interviewed, including five nurses, two family caregivers, and one patient.

Prenatally-diagnosed renal failure: an ethical framework for decision-making

The Children's Hospital Working Group has developed an ethical framework to guide patient care and research for prenatally diagnosed severe renal anomalies. It identifies ethical challenges in communication, timing of decisions and scarce resources. Key elements include shared decision-making, establishing a trusting relationship, and managing disagreement. The ethical framework will be used to develop a clinical pathway that operationalizes the key values of trust, honesty, transparency, beneficence, nonmaleficence, respecting parental authority, professional integrity, and justice.

Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report

In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.

Shared Decision-Making in Pediatrics

This article briefly reviews a 4-step process for implementing shared decision-making (SDM) in pediatrics. The authors address difficulties with determining whether SDM should occur and comment on how the SDM process relates to, and may be conflated with, other decision-making models that leverage similar patient-centered and family-centered communication strategies.

What Counts as a Surrogate Decision?

When patients lose decision-making capacity, others must make surrogate decisions on their behalf. What counts as a surrogate decision might seem self-evident. But as clinician-researchers in the field of advance care planning, we have found that it is not always so clear-cut. In this paper, we describe how and why this is a matter of concern, a novel approach for assessing whether a surrogate decision occurred, and findings from this assessment.