Development and pilot testing of a decision aid for surrogates of patients with prolonged mechanical ventilation

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.

Society of Critical Care Medicine Guidelines on Family-Centered Care for Adult ICUs: 2024

RATIONALE

For staff in adult ICUs, providing family-centered care is an essential skill that affects important outcomes for both patients and families. The COVID-19 pandemic placed unprecedented strain on care of ICU families, and practices for family engagement and support are still adjusting.

OBJECTIVES

To review updated evidence for family support in adult ICUs, provide clear recommendations, and spotlight optimal family-centered care practices post-pandemic.

PANEL DESIGN

The multiprofessional guideline panel of 28 individuals, including family member partners, applied the processes described in the Society of Critical Care Medicine Standard Operating Procedures Manual to develop and publish evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including panel selection, writing, and voting.

METHODS

The guidelines consist of four content sections: engagement of families, support of family needs, communication support, and support of ICU clinicians providing family-centered care. We conducted systematic reviews for 15 Population, Intervention, Control, and Outcomes questions, organized among these content sections, to identify the best available evidence. We summarized and assessed the certainty of evidence using the GRADE approach. We used the GRADE evidence-to-decision framework to formulate recommendations as strong or conditional, or as best practice statements where appropriate. The recommendations were approved using an online vote requiring greater than 80% agreement of voting panel members to pass.

RESULTS

Our panel issued 17 statements related to optimal family-centered care in adult ICUs, including one strong recommendation, 14 conditional recommendations, and two best practice statements. We reaffirmed the critical importance of liberalized family presence policies as default practice when possible and suggested options for family attendance on rounds and participation in bedside care. We suggested that ICUs provide support for families in the form of educational programs; ICU diaries; and mental health, bereavement, and spiritual support. We suggested the importance of providing structured communication for families and communication training for clinicians but did not recommend for or against any specific clinician-facing tools for family support or decision aids, based on current available evidence. We recommended that adult ICUs implement practices to systematically identify and reduce barriers to equitable critical care delivery for families and suggested that programs designed to support the wellbeing of clinicians responsible for family support be developed.

CONCLUSIONS

Our guideline panel achieved consensus regarding recommendations and best practices for family-centered care in adult ICUs.

Interventions for family involvement enhance end-of-life care for hospitalized patients: an integrative review

BACKGROUND

Integrating family members into the care of hospitalized end-of-life patients enhances patient-family-centered care and significantly influences the experiences of patients and their families. This study used the integrative review methodology to assess the scope and effectiveness of interventions designed to facilitate family involvement in end-of-life care. It identified gaps and consolidated existing knowledge to improve nursing practices.

METHODS

This integrative review encompasses both experimental and non-experimental studies. The process included problem identification, literature search, data evaluation, analysis, and integration. The literature search targeted studies describing interventions for family involvement in EOLC using databases such as PubMed, CINAHL, Embase, and Web of Science. Data evaluation was conducted by assessing the quality of the studies using the Mixed Methods Appraisal Tool. Data analysis and integration were conducted by synthesizing the results of the selected studies and identifying the elements of family involvement using the 'Components of Family Involvement' framework.

RESULTS

Of the 8,378 identified studies, 26 were eligible for inclusion. Interventions involving the families of patients with terminal illness varied, including programs to enhance communication among patients, families, and healthcare providers; family meetings; decision-making support; and digital visits and rounds. The findings show that these interventions improve patients' psychological and physical comfort, family satisfaction, and communication. However, some families reported increased distress. The most frequently addressed elements of family involvement were communication and receiving information, followed by decision-making and meeting care needs. Family presence and contribution to care were the least addressed elements in the interventions.

CONCLUSIONS

This integrative review highlights the effectiveness of interventions to increase family involvement in end-of-life care, demonstrating positive impacts on patient comfort, family satisfaction, and communication. Despite progress in incorporating families into communication and decision-making, further efforts are needed to ensure their presence and direct care involvement. Future research should focus on improving these interventions to enhance scalability and support comprehensive family involvement, including digital tools for participation.

Contents and effectiveness of patient- and family-centred care interventions in adult intensive care units: A systematic review

BACKGROUND

The need and values of patient- and family-centred care (PFCC) have been globally increasing in the health care landscape. However, the concept of PFCC and the components in adult intensive care units (ICUs) remain wide-ranging.

AIM

To elucidate the core concepts of PFCC interventions and evaluate the effects of the interventions in adult ICUs.

STUDY DESIGN

We searched electronic databases (PubMed, Cochrane Central, CINAHL, EMBASE, PsycINFO, RISS, KMbase and KoreaMed) from inception to 20 June 2022, for all studies on PFCC interventions. Three authors independently conducted data screening and extraction. The core concepts and the effects of PFCC interventions in adult ICUs were examined. The effects of patient- and family-centred care interventions in adult ICUs were examined. The quality of the included studies was evaluated using the Mixed Methods Appraisal Tool.

RESULTS

Overall, 3507 records were identified, and 14 full-text articles were assessed. Participants in the included studies were patients and/or their family members in adult ICUs. The main concepts of the studies were participation and information-sharing. Only two studies used collaboration as the main concept of intervention. PFCC interventions have shown positive outcomes for patients, including increased satisfaction, improvement of patient health status and reduced incidence of complications. They have also been beneficial for families, leading to higher satisfaction levels and decreased anxiety. Additionally, these interventions have positively impacted health care providers by enhancing satisfaction and improving rounding efficiency. Moreover, they have influenced health care utilization by decreasing hospital costs and length of stay.

CONCLUSIONS

This review highlights the advantages of PFCC interventions for patients, families and health care providers in adult ICUs. Future research should focus on developing strategies to incorporate collaboration more comprehensively as a core concept in the implementation of PFCC interventions.

RELEVANCE TO CLINICAL PRACTICE

Future research endeavours must prioritize collaborative efforts involving health care providers, patients and their families by deploying an array of strategies within the intensive care unit setting.

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.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Decision Aids in the ICU: a scoping review

OBJECTIVE

The purpose of this scoping review was to synthesise the effectiveness and acceptability of decision aids for critically ill patients and family members in the intensive care unit (ICU).

METHODS

A systematic search of four electronic databases and grey literature was undertaken to identify relevant studies on the application of decision aids in the ICU, without publication date restriction, through March 2023. The methodological framework proposed by Arksey and O'Malley was used to guide the scoping review.

RESULTS

Fourteen papers were ultimately included in this review. However, only nine decision aids were available, and it is noteworthy that many of these studies focused on the iterative development and testing of individual decision aids. Among the included studies, 92% (n=13) were developed in North America, with a primary focus on goals of care and life-sustaining treatments. The summary of the effect of decision aid application revealed that the most common indicators were the level of knowledge and code status, and some promising signals disappeared in randomised trials.

CONCLUSIONS

The complexity of treatment decisions in the ICU exceeds the current capabilities of existing decision aids. There is a clear gap in decision aids that are tailored to different cultural contexts, highlighting the need to expand the scope of their application. In addition, rigorous quality control is very important for randomised controlled trial, and indicators for assessing the effectiveness of decision aids need to be further clarified.

Do They Have a Choice? Surrogate Decision-Making After Severe Acute Brain Injury

OBJECTIVES

In the early phase of severe acute brain injury (SABI), surrogate decision-makers must make treatment decisions in the face of prognostic uncertainty. Evidence-based strategies to communicate uncertainty and support decision-making are lacking. Our objective was to better understand surrogate experiences and needs during the period of active decision-making in SABI, to inform interventions to support SABI patients and families and improve clinician-surrogate communication.

DESIGN

We interviewed surrogate decision-makers during patients' acute hospitalization for SABI, as part of a larger ( n = 222) prospective longitudinal cohort study of patients with SABI and their family members. Constructivist grounded theory informed data collection and analysis.

SETTING

One U.S. academic medical center.

PATIENTS

We iteratively collected and analyzed semistructured interviews with 22 surrogates for 19 patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Through several rounds of coding, interview notes, reflexive memos, and group discussion, we developed a thematic model describing the relationship between surrogate perspectives on decision-making and surrogate experiences of prognostic uncertainty. Patients ranged from 20 to 79 years of age (mean = 55 years) and had primary diagnoses of stroke ( n = 13; 68%), traumatic brain injury ( n = 5; 26%), and anoxic brain injury after cardiac arrest ( n = 1; 5%). Patients were predominantly male ( n = 12; 63%), whereas surrogates were predominantly female ( n = 13; 68%). Two distinct perspectives on decision-making emerged: one group of surrogates felt a clear sense of agency around decision-making, whereas the other group reported a more passive role in decision-making, such that they did not even perceive there being a decision to make. Surrogates in both groups identified prognostic uncertainty as the central challenge in SABI, but they managed it differently. Only surrogates who felt they were actively deciding described time-limited trials as helpful.

CONCLUSIONS

In this qualitative study, not all surrogate "decision-makers" viewed themselves as making decisions. Nearly all struggled with prognostic uncertainty. Our findings underline the need for longitudinal prognostic communication strategies in SABI targeted at surrogates' current perspectives on decision-making.

Fielding the quality of communication questionnaire to persons with cognitive impairment and their family in primary care: A pilot study

BACKGROUND

The quality of communication (QOC) questionnaire has been widely used to assess foundational aspects of patient-clinician communication about end-of-life (EOL) care. However, this instrument has never before been fielded with primary care patients who have cognitive impairment and their caregivers, a population with unique communication needs.

DESIGN

We report on baseline data from a completed pilot study and ongoing efficacy trial of advance care planning involving dyads of primary care patients ages 80 and older with cognitive impairment and their family care partners. Two QOC subscales assessed ratings of general communication and EOL care communication from 0 ("worst") to 10 ("best"). Due to challenges piloting the EOL subscale, we integrated skip logic to improve cognitive accessibility and measurement precision. Participants were first asked whether EOL communication occurred (yes/no); those responding affirmatively were subsequently asked to rate communication. We report experiences with EOL subscale adaptations from our ongoing trial (NCT04593472).

RESULTS

Using the original instrument in our pilot (13 dyads), mean patient and family general communication ratings were similar (9.65 and 9.60, respectively), but EOL ratings diverged (4.23 and 5.88, respectively), and "Don't Know" comprised 5% of patient and 32% of family responses. Interviewers reported patient and family participants expressed confusion when asked to rate EOL communication behaviors that had not occurred. Using the adapted instrument in our efficacy trial (43 dyads), EOL communication behaviors were most often reported as not having occurred (76% of patient and 73% of family responses across all items). Mean patient and family EOL subscale ratings were similar (2.23 and 2.26) and responses of "Don't Know" were minimal (<1%).

CONCLUSION

The original QOC EOL subscale involves rating conversations that rarely occur in primary care but are important for older adults with cognitive impairment. Subscale adaptations may reduce confusion and response uncertainty and improve measurement accuracy.

Decision-Support Needs of Caregivers Considering Hospice Enrollment for a Family Member With Dementia

Background: There are few evidence-based interventions to support the growing number of family caregivers of persons living with advanced dementias (PWADs) in surrogate decision-making roles. This study identifies needs for decision support among family caregivers considering hospice enrollment for PWADs, in order to better inform efforts for decision support. Method: Individual and focus group interviews were conducted with caregivers (n = 13) and healthcare professionals (n = 14). Directed content analysis was used to identify and organize themes that emerged from interview transcripts. Results: Analysis revealed 2 themes concerning PWAD caregivers' hospice-related decision-support needs: (1) detailed and practical information about hospice and (2) discussions clarifying meaning around quality of life (QOL) for PWADs. Caregivers needed to know when they should consider hospice, what treatments would be stopped, what services would help caregivers, and what costs would be involved. Caregivers varied in their perceptions of what it might mean for a PWAD to have QOL at the end of life and whether or not hospice would enhance it. Discussion: This study's findings underscore the importance of decision-support tools and patient- and family-centered education for PWADs and caregivers about the trajectory of dementia and end-stage symptoms, along with practical information for hospice care planning and discussions addressing end of life values.

ProPACC: Protocol for a Trial of Integrated Specialty Palliative Care for Critically Ill Older Adults

BACKGROUND

Each year, approximately one million older adults die in American intensive care units (ICUs) or survive with significant functional impairment. Inadequate symptom management, surrogates' psychological distress and inappropriate healthcare use are major concerns. Pioneering work by Dr. J. Randall Curtis paved the way for integrating palliative care (PC) specialists to address these needs, but convincing proof of efficacy has not yet been demonstrated.

DESIGN

We will conduct a multicenter patient-randomized efficacy trial of integrated specialty PC (SPC) vs. usual care for 500 high-risk ICU patients over age 60 and their surrogate decision-makers from five hospitals in Pennsylvania.

INTERVENTION

The intervention will follow recommended best practices for inpatient PC consultation. Patients will receive care from a multidisciplinary SPC team within 24 hours of enrollment that continues until hospital discharge or death. SPC clinicians will meet with patients, families, and the ICU team every weekday. SPC and ICU clinicians will jointly participate in proactive family meetings according to a predefined schedule. Patients in the control arm will receive routine ICU care.

OUTCOMES

Our primary outcome is patient-centeredness of care, measured using the modified Patient Perceived Patient-Centeredness of Care scale. Secondary outcomes include surrogates' psychological symptom burden and health resource utilization. Other outcomes include patient survival, as well as interprofessional collaboration. We will also conduct prespecified subgroup analyses using variables such as PC needs, measured by the Needs of Social Nature, Existential Concerns, Symptoms, and Therapeutic Interaction scale.

CONCLUSIONS

This trial will provide robust evidence about the impact of integrating SPC with critical care on patient, family, and health system outcomes.

Decision Making for Infants With Neurologic Conditions

Parents and clinicians caring for infants with neurologic disease often make high-stakes decisions about infant care. To characterize how these decisions occur, we enrolled infants with neurologic conditions, their parents, and their clinicians in a longitudinal mixed methods study of decision making. We audio recorded family conferences as they occurred and analyzed conferences using a directed content analysis approach. We enrolled 40 infants and 61 parents who participated in 68 family conferences. Thirty-seven conferences contained a treatment decision. We identified 4 key domains of the decision-making process: medical information exchange, values-based exchange, therapeutic partnership, and integration of values into decision making. Discussion of values was typically parent initiated (n = 20, 83%); approximately one-third of conferences did not contain any discussion of parent values. Integration of family values and preferences into decision making occurred in approximately half of conferences. These findings highlight opportunities for interventions that promote values discussion and the integration of values into decision making.

Development of a core outcome set for the evaluation of interventions to enhance trial participation decisions on behalf of adults who lack capacity to consent: a mixed methods study (COnSiDER Study)

BACKGROUND

Trials involving adults who lack capacity to provide consent rely on proxy or surrogate decision-makers, usually a family member, to make decisions about participation. Interventions to enhance proxy decisions about trial participation are now being developed. However, a lack of standardised outcome measures limits evaluation of these interventions. The aim of this study was to establish an agreed standardised core outcome set (COS) for use when evaluating interventions to improve proxy decisions about trial participation.

METHODS

We used established methods to develop the COS including a consensus study with key stakeholder groups comprising those who will use the COS in research (researchers and healthcare professionals) and patients or their representatives. Following a scoping review to identify candidate items, we used a modified two-round Delphi survey to achieve consensus on core outcomes, with equivocal items taken to a consensus meeting for discussion. The COS was finalised following an online consensus meeting in October 2020.

RESULTS

A total of 28 UK stakeholders (5 researchers, 10 trialists, 3 patient/family representatives, 7 recruiters and 3 advisors/approvers) participated in the online Delphi survey to rank candidate items from the scoping review (n = 36) and additional items proposed by participants (n = 1). Items were broadly grouped into three categories: how family members make decisions, their experiences of making decisions, and the personal aspects that influence the decision. Following the Delphi survey, 27 items were included and ten items exhibited no consensus which required discussion at the consensus meeting. Sixteen participants attended the meeting, including additional patient/family representatives invited to increase representation from this key group (n = 2). We reached consensus for the inclusion of 28 outcome items, including one selected at the consensus meeting.

CONCLUSIONS

The study identified outcomes that should be measured as a minimum in all evaluations of interventions to enhance proxy decisions about trials. These relate to the process of decision-making, proxies' experience of decision-making, and factors that influence decision-making such as understanding. Further work with people with impairing conditions and their families is needed to explore their views about the COS and to identify appropriate outcome measures and timing of measurement.

TRIAL REGISTRATION

The study is registered on the COMET database ( https://www.comet-initiative.org/Studies/Details/1409 ).

End-of-Life Care Decision-Making in Stroke

Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.

Evaluating the Balance Between Privacy and Access in Digital Information Sharing

Supplemental Digital Content is available in the text.

Access to personal health records in an ICU by persons involved in the patient’s care (referred to broadly as “family members” below) has the potential to increase engagement and reduce the negative psychologic sequelae of such hospitalizations. Currently, little is known about patient preferences for information sharing with a designated family member in the ICU. We sought to understand the information-sharing preferences of former ICU patients and their family members and to identify predictors of information-sharing preferences.

Surrogates and Physician Preferences regarding the Continuation of Mechanical Ventilation among Critically Ill Adults

Rationale: For an incapacitated patient who is difficult to liberate from mechanical ventilation, surrogates and physicians will decide to continue life support if they believe doing so is consistent with the patient's prognosis and values. Little is known about the factors that surrogates and physicians prioritize during this decision-making process, in part because there is not a validated method to assess their preferences.Objectives: To evaluate trends in surrogate and physician preferences for continuing mechanical ventilation.Methods: One hundred surrogates and respective physicians of patients requiring mechanical ventilation for at least 7 days were prospectively enrolled at an academic, tertiary care medical center. During the second and third week of mechanical ventilation, participant preferences for continuing mechanical ventilation were assessed in two ways, the first emphasizing patient survival and the second emphasizing patient comfort as the primary goal.Results: During the patient's second week of mechanical ventilation, surrogates agreed more strongly than did physicians that mechanical ventilation should be continued to maximize the chance for patient survival (73% vs. 63%, respectively, P = 0.02 for difference). In contrast, at this same point in time, surrogates and physicians agreed similarly that mechanical ventilation should be discontinued to maximize patient comfort (37% vs. 38%, respectively, P = 0.34 for difference). Both surrogates and physicians agreed less strongly during week 3 than they did during week 2 that mechanical ventilation should be continued with a goal of maximizing patient survival, with preferences to limit the use of mechanical ventilation for patients with the poorest prognoses according to physiological variables. In contrast, only physicians agreed more strongly during week 3 than they did during week 2 that mechanical ventilation should be discontinued to maximize patient comfort.Conclusions: Level of surrogate and physician agreement that mechanical ventilation should be continued to maximize the chance for patient survival reflected their preferences more accurately than level of surrogate and physician agreement that mechanical ventilation should be discontinued to maximize patient comfort. Over time, surrogates and physicians were less likely to agree that mechanical ventilation should be continued, particularly when patients had poor prognoses.

Development of a decision support intervention for family members of adults who lack capacity to consent to trials

BACKGROUND

Informed consent is required for participation in clinical trials, however trials involving adults who lack capacity to consent require different enrolment processes. A family member usually acts as a proxy to make a decision based on the patient's 'presumed will', but these decisions can be challenging and families may experience an emotional and decisional burden. Decisions made on behalf of others are conceptually different from those made for ourselves. Innovations have been developed to improve informed consent processes for research, including a number of decision aids, however there are no interventions for proxies who are faced with more complex decisions. This article outlines the development of a novel decision aid to support families making decisions about research participation on behalf of an adult who lacks capacity to consent.

METHODS

Decision support interventions should be developed using rigorous and evidence-based methods. This intervention was developed using MRC guidance for the development of complex interventions, and a conceptual framework for the development and evaluation of decision aids for people considering taking part in a clinical trial. The intervention was informed by a systematic review and analysis of existing information provision. Previous qualitative research with families who acted as proxies enabled the development of a theoretical framework to underpin the intervention. The intervention was iteratively developed with the involvement of lay advisors and relevant stakeholders.

RESULTS

Previous research, theoretical frameworks, and decision aid development frameworks were used to identify and develop the intervention components. The decision aid includes information about the proxy's role and utilises a values clarification exercise and decision support methods to enable a more informed and better-quality decision. Stakeholders, including those representing implementers and receivers of the intervention, contributed to the design and comprehensibility of the decision aid to ensure that it would be acceptable for use.

CONCLUSIONS

Frameworks for the development of decision aids for people considering participating in a clinical trial can be used to develop interventions for family members acting as proxy decision-makers. The decision support tool is acceptable to users. Feasibility testing and outcome measure development is required prior to any evaluation of its effectiveness.

Enhancing Communication With Family Members in the Intensive Care Unit: A Mixed-Methods Study

Background

Nurses in the intensive care unit are central to clinical care delivery and are often the staff members most accessible to family members for communication. Family members’ ratings of satisfaction with the intensive care unit admission are affected more by communication quality than by the level of care for the patient. Family members may feel that communication in the intensive care unit is inconsistent.

Objectives

To use a shared decision-making model to deliver a communication education program for intensive care unit nurses, evaluate the confidence levels of nurses who undertook the education, and examine changes in family members’ satisfaction with communication from intensive care unit nurses after the nurses received the education.

Methods

A mixed-methods design was used. Seventeen nurses and 81 family members participated.

Results

Staff members were overall very confident with communicating with family members of critically ill patients. This finding was likely linked to staff members’ experience in the position, with 88% of nurses having more than 11 years’ experience. Family members were happy with care but dissatisfied with the environment.

Conclusions

Environmental factors can negatively affect communication with family members in the intensive care unit.

Does the use of patient decision aids lead to cost savings? a systematic review

OBJECTIVES

To update a previous systematic review to determine if patient decision aid (PDA) interventions generate savings in healthcare settings, and if so, from which perspective (ie, patient, organisation providing care, society).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, Web of Science, Cochrane Library, Embase, Campbell Collaboration Library, EconLit, Business Source Complete, Centre for Reviews and Dissemination: NHS Economic Evaluations Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) from 15 March 2013 to 25 January 2019. The references of studies that met the eligibility criteria and any publications related to conference abstracts or registered clinical trials were reviewed to increase the sensitivity of the search.

ELIGIBILITY CRITERIA

Full and partial economic evaluations with an experimental, quasi-experimental or randomised controlled design were included. The intervention had to satisfy the pre-determined minimum conditions necessary to be defined as a PDA, and (for full evaluations) provide details on the comparator used.

DATA EXTRACTION AND SYNTHESIS

All study outcomes and economic data were extracted. The reporting and quality of the economic analyses were independently assessed by two health economists.

RESULTS

Of 5066 studies, 22 studies were included, including the 8 studies from the previous review. Twelve studies reported cost-savings (range=US$10 to US$81 156; US dollars in 2020), primarily from the organisational or health system perspective, and 10 studies did not. However, due to the quality of the economic analyses, and the related issues with the interpretative validity of results it would be inappropriate to say that PDAs will generate savings, from any perspective.

CONCLUSIONS

It is unclear whether PDAs will generate savings. Greater consensus on what constitutes a PDA and the need to compare them against usual care over a sufficient time horizon to allow valid assessment of costs and outcomes is required.

PROSPERO REGISTRATION NUMBER

CRD42019118457.

A Randomized Comparative Trial to Evaluate a PICU Navigator-Based Parent Support Intervention

OBJECTIVES

Communication breakdowns in PICUs contribute to inadequate parent support and poor post-PICU parent outcomes. No interventions supporting communication have demonstrated improvements in parental satisfaction or psychologic morbidity. We compared parent-reported outcomes from parents receiving a navigator-based parent support intervention (PICU Supports) with those from parents receiving an informational brochure.

DESIGN

Patient-level, randomized trial.

SETTING

Two university-based, tertiary-care children's hospital PICUs.

PARTICIPANTS

Parents of patients requiring more than 24 hours in the PICU.

INTERVENTIONS

PICU Supports included adding a trained navigator to the patient's healthcare team. Trained navigators met with parents and team members to assess and address communication, decision-making, emotional, informational, and discharge or end-of-life care needs; offered weekly family meetings; and did a post-PICU discharge parent check-in. The comparator arm received an informational brochure providing information about PICU procedures, terms, and healthcare providers.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was percentage of "excellent" responses to the Pediatric Family Satisfaction in the ICU 24 decision-making domain obtained 3-5 weeks following PICU discharge. Secondary outcomes included parental psychologic and physical morbidity and perceptions of team communication. We enrolled 382 families: 190 received PICU Supports, and 192 received the brochure. Fifty-seven percent (216/382) completed the 3-5 weeks post-PICU discharge survey. The mean percentage of excellent responses to the Pediatric Family Satisfaction in the ICU 24 decision-making items was 60.4% for PICU Supports versus 56.1% for the brochure (estimate, 3.57; SE, 4.53; 95% CI, -5.77 to 12.90; p = 0.44). Differences in secondary outcomes were not statistically significant. Most parents (91.1%; 113/124) described PICU Supports as "extremely" or "somewhat" helpful.

CONCLUSIONS

Parents who received PICU Supports rated the intervention positively. Differences in decision-making satisfaction scores between those receiving PICU Supports and a brochure were not statistically significant. Interventions like PICU Supports should be evaluated in larger studies employing enhanced recruitment and retention of subjects.

Development and usability testing of Understanding Stroke, a tailored life-sustaining treatment decision support tool for stroke surrogate decision makers

BACKGROUND

Surrogate decision makers of stroke patients are often unprepared to make critical decisions on life-sustaining treatments. We describe the development process and key features for the Understanding Stroke web-based decision support tool.

METHODS

We used multiple strategies to develop a patient-centered, tailored decision aid. We began by forming a Patient and Family Advisory Council to provide continuous input to our multidisciplinary team on the development of the tool. Additionally, focus groups consisting of nurses, therapists, social workers, physicians, stroke survivors, and family members reviewed key elements of the tool, including prognostic information, graphical displays, and values clarification exercise. To design the values clarification exercise, we asked focus groups to provide feedback on a list of important activities of daily living. An ordinal prognostic model was developed for ischemic stroke and intracerebral hemorrhage using data taken from the Virtual International Stroke Trials Archive Plus, and incorporated into the tool.

RESULTS

Focus group participants recommended making numeric prognostic information optional due to possible emotional distress. Pie charts were generally favored by participants for graphical presentation of prognostic information, though a horizontal stacked bar chart was also added due to its prevalence in stroke literature. Plain language descriptions of the modified Rankin Scale were created to accompany the prognostic information. A values clarification exercise was developed consisting of a list of 13 situations that may make an individual consider comfort measures only. The final version of the web based tool (which can be viewed on tablets) included the following sections: general introduction to stroke, outcomes (prognostic information and recovery), in-hospital and life-sustaining treatments, decision making and values clarification, post-hospital care, tips for talking to the health care team, and a summary report. Preliminary usability testing received generally favorable feedback.

CONCLUSION

We developed Understanding Stroke, a tailored decision support tool for surrogate decision makers of stroke patients. The tool was well received and will be formally pilot tested in a group of stroke surrogate decision makers.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03427645 ).

Navigator-Based Intervention to Support Communication in the Pediatric Intensive Care Unit: A Pilot Study

BACKGROUND

Communication in the pediatric intensive care unit (PICU) between families and the health care team affects the family experience, caregiver psychological morbidity, and patient outcomes.

OBJECTIVE

To test the feasibility of studying and implementing a PICU communication intervention called PICU Supports, and to assess families' and health care teams' perceptions of the intervention.

METHODS

This study involved patients requiring more than 24 hours of PICU care. An interventionist trained in PICU-focused health care navigation, a "navigator," met with parents and the health care team to discuss communication, decision-making, emotional, informational, and discharge or end-of-life care needs; offered weekly family meetings; and checked in with parents after PICU discharge. The feasibility of implementing the intervention was assessed by tracking navigator activities. Health care team and family perceptions were assessed using surveys, interviews, and focus groups.

RESULTS

Of 53 families approached about the study, 35 (66%) agreed to participate. The navigator met with parents on 71% and the health care team on 85% of possible weekdays, and completed 86% of the postdischarge check-ins. Family meetings were offered to 95% of eligible patients. The intervention was rated as helpful by 97% of parents, and comments during interviews were positive.

CONCLUSIONS

The PICU Supports intervention is feasible to implement and study and is viewed favorably by parents.

Goals-of-care decision aid for critically ill patients with TBI: Development and feasibility testing

OBJECTIVE

To develop and demonstrate early feasibility of a goals-of-care decision aid for surrogates of patients who are critically ill with traumatic brain injury (ciTBI) that meets accepted international decision aid guidelines.

METHODS

We developed the decision aid in 4 stages: (1) qualitative study of goals-of-care communication and decision needs of 36 stakeholders of ciTBI (surrogates and physicians), which informed (2) development of paper-based decision aid with iterative revisions after feedback from 52 stakeholders; (3) acceptability and usability testing in 18 neurologic intensive care unit (neuroICU) family members recruited from 2 neuroICU waiting rooms using validated scales; and (4) open-label, randomized controlled feasibility trial in surrogates of ciTBI. We performed an interim analysis of 16 surrogates of 12 consecutive patients who are ciTBI to confirm early feasibility of the study protocol and report recruitment, participation, and retention rates to date.

RESULTS

The resultant goals-of-care decision aid achieved excellent usability (median System Usability Scale 87.5 [possible range 0-100]) and acceptability (97% graded the tool's content as "good" or "excellent"). Early feasibility of the decision aid and the feasibility trial protocol was demonstrated by high rates of recruitment (73% consented), participation (100%), and retention (100% both after the goals-of-care clinician-family meeting and at 3 months) and complete data for the measurements of all secondary decision-related and behavioral outcomes to date.

CONCLUSIONS

Our systematic development process resulted in a novel goals-of-care decision aid for surrogates of patients who are ciTBI with excellent usability, acceptability, and early feasibility in the neuroICU environment, and meets international decision aid standards. This methodology may be a development model for other decision aids in neurology to promote shared decision-making.

One-Year Outcomes Following Tracheostomy for Acute Respiratory Failure

OBJECTIVES

Tracheostomy utilization has dramatically increased recently. Large gaps exist between expected and actual outcomes resulting in significant decisional conflict and regret. We determined 1-year patient outcomes and healthcare utilization following tracheostomy to aid in decision-making and resource allocation.

DESIGN

Retrospective cohort study.

SETTING

All California hospital discharges from 2012 to 2013 with follow-up through 2014.

PATIENTS

Nonsurgical patients who received a tracheostomy for acute respiratory failure.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome was 30-day, 90-day, and 1-year mortality. We also determined hospitals readmissions rates and healthcare utilization in the first year following tracheostomy. We identified 8,343 tracheostomies during the study period. One-year mortality following tracheostomy was high, 46.5%. Older adults (≥ 65 yr) had significantly higher mortality compared with younger patients (< 65 yr) (54.7% vs 36.5%; p < 0.0001). Median survival for older adults was 175 days (95% CI, 150-202 d) compared with greater than 1 year for younger adults (adjusted hazard ratio, 1.25; 95% CI, 1.14-1.36). Within 1 year of tracheostomy, 60.3% of patients required hospital readmission. Older adults were more likely to be readmitted in the first year after tracheostomy compared with younger adults (66.1% vs 55.2%; adjusted hazard ratio, 1.19; 95% CI, 1.09-1.29). Total short-term acute care hospital costs (index and readmissions) in the first year after tracheostomy were high (mean, $215,369; SD, $160,874).

CONCLUSIONS

Long-term outcomes following tracheostomy are extremely poor with high mortality, morbidity, and healthcare resource utilization especially among older patients. Some subsets of younger patients may have better outcomes compared with the general tracheostomy population. Short-term acute care costs were extremely high in the first year following tracheostomy. If extended to the entire U.S. population, total short-term acute care hospital costs approach $11 billion dollars per year for tracheostomy-related to acute respiratory failure. These findings may aid families and surrogates in the decision-making process.

A Multicenter Study of the Causes and Consequences of Optimistic Expectations About Prognosis by Surrogate Decision-Makers in ICUs

OBJECTIVES

Optimistic expectations about prognosis by surrogate decision-makers in ICUs are common, but there are few data about the causes and clinical consequences. Our objective was to determine the causes of optimistic expectations about prognosis among surrogates and whether it is associated with more use of life support at the end of life.

DESIGN

Prospective, multicenter cohort study from 2009 to 2012.

SETTING

Twelve ICUs from multiple regions of the United States.

SUBJECTS

The surrogates and physicians of 275 incapacitated ICU patients at high risk of death.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Surrogates and physicians completed a validated instrument assessing their prognostic expectations for hospital survival. We determined the proportion of surrogates with optimistic expectations, defined as a prognostic estimate that was at least 20% more optimistic than the physician's, then determined how frequently this arose from surrogates miscomprehending the physicians' prognosis versus holding more hopeful beliefs compared with the physician. We used multivariable regression to examine whether optimistic expectations were associated with length of stay, stratified by survival status, and time to withdrawal of life support among nonsurvivors. Overall, 45% of surrogates (95% CI, 38-51%) held optimistic expectations about prognosis, which arose from a combination of misunderstanding the physician's prognostic expectations and from holding more hopeful beliefs compared with the physician. Optimistic expectations by surrogates were associated with significantly longer duration of ICU treatment among nonsurvivors before death (β coefficient = 0.44; 95% CI, 0.05-0.83; p = 0.027), corresponding to a 56% longer ICU stay. This difference was associated with a significantly longer time to withdrawal of life support among dying patients whose surrogates had optimistic prognostic expectations compared with those who did not (β coefficient = 0.61; 95% CI, 0.16-1.07; p = 0.009).

CONCLUSIONS

The prevalent optimism about prognosis among surrogates in ICUs arises both from surrogates' miscomprehension of physicians' prognostications and from surrogates holding more hopeful beliefs. This optimism is associated with longer duration of life support at the end of life.

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

OBJECTIVES

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

DESIGN, SETTING, AND PATIENTS

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

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Development and field testing of a tool to elicit women's preferences among cervical cancer screening modalities

OBJECTIVE

The objective of the present study is to describe the development and field testing of a preference-elicitation tool for cervical cancer screening, meeting International Patient Decision Aids Standards (IPDAS) quality criteria.

METHODS

We developed a tool designed to elicit women's preferences among cervical cancer screening modalities. The Ottawa Decision Support Framework and IPDAS systematic development process guided the design, and we followed IPDAS criteria for conducting a field test in a real-world setting. Using social media recruitment strategies, we identified a convenience sample of Ontario women who were currently eligible for cervical screening to test the tool. We evaluated the feasibility, acceptability, balance of information, and ability to elicit women's informed, values-based preferences using an online survey embedded in the tool.

RESULTS

Twenty-five women participated in the field test. Participants were aged 20 to 63 years , and identified as predominantly white (88%), living in Northern Ontario (68%), and most had university education (75%). Most participants (72%) considered the length of the website as "just right," and 100% indicated that they would find the tool useful for decision-making. Over two-thirds (68%) of participants perceived the information in the tool as "balanced." Almost all (92%) participants scored at least 4 out of 7 on the knowledge quiz, and most participants (84%) selected their preference in an informed, values-based way.

CONCLUSION

The results from our field test of this tool provide preliminary evidence of the tool's feasibility, acceptability, balance, and ability to elicit women's informed, values-based preferences among available cervical screening modalities. Further research should elicit the distribution of preferences of cervical screening modalities in other regions, using a sample who represents the screening population and a rigorous study design. It will be important for researchers and screening programmes to evaluate the tool's ability to elicit women's informed, values-based preferences compared with educational materials.

Selecting the Best Instrument to Measure Family Perceptions of End-of-Life Communication in Intensive Care Units

BACKGROUND

Good communication with the family is a clinical imperative for high quality end-of-life (EOL) care in intensive care unit (ICU). Many interventions aim to improve EOL communication, and the choice of an outcome instrument has important implications for evaluating interventions. The purpose of this project is to search and review available instruments' psychometric properties and determine which best measures family-clinician communication in the ICU.

METHOD

A stepwise method was used by searching 2 databases (PsycInfo and Web of Science) to identify instruments and articles that provide information about scale psychometric properties.

INSTRUMENTS

Three instruments were identified, including Family Inpatient Communication Survey, Family Perception of Physician-Family Caregiver Communication, and Quality of Communication (QOC).

RESULTS

Reliability estimates were high (≥ 0.79) in all 3 instruments. The QOC's convergent validity estimates exceed its discriminant validity values, and the QOC is an intervention-sensitive measure used to examine families' treatment response in randomized control trials.

CONCLUSION

Quality of Communication is the most suitable instrument to measure family's perceptions of EOL communication in the ICU. Quality of Communication scores provide a deeper understanding of family-clinician communication and data about how to improve EOL care in ICUs.

Patient and Family Centered Actionable Processes of Care and Performance Measures for Persistent and Chronic Critical Illness: A Systematic Review

Supplemental Digital Content is available in the text.

To identify actionable processes of care, quality indicators, or performance measures and their evidence base relevant to patients with persistent or chronic critical illness and their family members including themes relating to patient/family experience.

Barriers to Goal-concordant Care for Older Patients With Acute Surgical Illness: Communication Patterns Extrinsic to Decision Aids

OBJECTIVE

We sought to characterize patterns of communication extrinsic to a decision aid that may impede goal-concordant care.

BACKGROUND

Decision aids are designed to facilitate difficult clinical decisions by providing better treatment information. However, these interventions may not be sufficient to effectively reveal patient values and promote preference-aligned decisions for seriously ill, older adults.

METHODS

We conducted a secondary analysis of 31 decision-making conversations between surgeons and frail, older inpatients with acute surgical problems at a single tertiary care hospital. Conversations occurred before and after surgeons were trained to use a decision aid. We used directed qualitative content analysis to characterize patterns within 3 communication elements: disclosure of prognosis, elicitation of patient preferences, and integration of preferences into a treatment recommendation.

RESULTS

First, surgeons missed an opportunity to break bad news. By focusing on the acute surgical problem and need to make a treatment decision, surgeons failed to expose the life-limiting nature of the patient's illness. Second, surgeons asked patients to express preference for a specific treatment without gaining knowledge about the patient's priorities or exploring how patients might value specific health states or disabilities. Third, many surgeons struggled to integrate patients' goals and values to make a treatment recommendation. Instead, they presented options and noted, "It's your decision."

CONCLUSIONS

A decision aid alone may be insufficient to facilitate a decision that is truly shared. Attention to elements beyond provision of treatment information has the potential to improve communication and promote goal-concordant care for seriously ill older patients.

Parental Personal Sense of Duty as a Foundation of Pediatric Medical Decision-making

We describe a model of parental (or more broadly, surrogate) decision-making that includes 5 aspects of decision-making that other models simplify or omit. First, we describe problem structuring recognizing that parents often face multiple potential problems or decisions with multiple potential solutions, rather than a single problem, and the initial challenge is deciding which of the problems to focus on. Second, we discuss sense-making recognizing that difficult decisions are not made in isolation but are often part of a confusing, labyrinthian situation in which disoriented parents must make a series of decisions over time in hopes of getting closer to 1 or more goals. Third, we describe path dependency recognizing that decisions influence what and how decisions are made later. Fourth, we discuss personal sense of duty recognizing that parents and other surrogate decision-makers have central personal roles, self-identities, and relationships with the patient, culminating in a personal sense of duty, such as what they perceive they should do to be in their own judgment a "good parent," which substantially affects their decision-making. Fifth, we describe self-judgments recognizing that parents experience distress when they judge themselves as falling short of their duties or if they think others are judging them for falling short. Clinical practice, medical ethics, and research regarding decision support can all benefit by acknowledging and addressing these key aspects of medical decision-making.

Caregivers of Patients Considering a Destination Therapy Left Ventricular Assist Device and a Shared Decision-Making Intervention: The DECIDE-LVAD Trial

OBJECTIVES

This study aims to characterize caregivers of patients considering destination therapy left ventricular assist device (DT-LVAD) and evaluate the effectiveness of a shared decision-making (SDM) intervention.

BACKGROUND

Caregivers play an integral role in the care of patients with chronic illness. At the extreme, pursuing a DT-LVAD is a major preference-sensitive decision that requires high-level caregiver engagement. Yet, little is known about caregivers of patients considering DT-LVAD, and there is a paucity of research on the involvement of caregivers in medical decision-making.

METHODS

A 6-center, stepped-wedge trial was conducted. After varying time in usual care (control), sites were transitioned to an SDM intervention consisting of staff education and pamphlet and video decision aids (DAs). The primary outcome was decision quality, measured by knowledge and values-choice concordance.

RESULTS

From 2015 to 2017, 182 caregivers of patients considering DT-LVAD were enrolled (control group, n = 111; intervention group, n = 71). The median age was 61 years, 86.5% were female, and 75.8% were spouses. Caregiver knowledge (0% to 100%) improved from baseline to post-education in both groups: in the control group it improved from 64.2% to 73.3%; in the intervention group it improved from 62.6% to 76.4% (adjusted difference of difference: 4.8%; p = 0.08). At 1 month, correlation between stated values and caregiver-reported treatment choice was stronger in the intervention group (difference in Kendall's tau: 0.36, 95% confidence interval: 0.04 to 0.71; p = 0.03). Caregivers reported decisional conflict (0 to 100) at baseline (control group: 19.0 ± 2.1; intervention group: 21.4 ± 2.6), which decreased post-education more in the control group (control group: 9.0 ± 1.9, intervention group: 18.8 ± 2.4; p = 0.009). Caregivers in the control group were more likely to "definitely recommend" the educational materials than those in the intervention group (93.5% vs. 74.5%, respectively; p = 0.004).

CONCLUSIONS

An SDM intervention improved concordance between caregiver values and treatment choice for their loved ones but did not significantly impact knowledge. Caregivers found the DAs less acceptable than more biased educational materials and exposure to DAs led to higher conflict initially. These findings highlight the complexity of SDM involving caregivers of patients with chronic illness. (PCORI-1310-06998 Trial of a Decision Support Intervention for Patients and Caregivers Offered Destination Therapy Heart Assist Device [DECIDE-LVAD]; NCT02344576).

Pediatric palliative care in the intensive care unit and questions of quality: a review of the determinants and mechanisms of high-quality palliative care in the pediatric intensive care unit (PICU)

This article reviews the state and practice of pediatric palliative care (PC) within the pediatric intensive care unit (PICU) with specific consideration of quality issues. This includes defining PC and end of life (EOL) care. We will also describe PC as it pertains to alleviating children's suffering through the provision of "concurrent care" in the ICU environment. Modes of care, and attendant strengths, of both the consultant and integrated models will be presented. We will review salient issues related to the provision of PC in the PICU, barriers to optimal practice, parental, and staff perceptions. Opportunity areas for quality improvement and the role of initiatives and measures such as education, family-based initiatives, staff needs, symptom recognition, grief, and communication follow. To conclude, we will look to the literature for PC resources for pediatric intensivists and future directions of study.

Shared Decision Making in Neurocritical Care

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Shared Decision Making in Neurocritical Care

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

The effectiveness of interventions to meet family needs of critically ill patients in an adult intensive care unit: a systematic review update

BACKGROUND

Attending to the needs of family members of critically ill patients is an important and necessary step in providing appropriate holistic care for both the patient and the family. Family interaction can significantly impact on the experience of critical illness, notwithstanding the challenge of meeting families' needs for many clinicians in the intensive care unit (ICU). Family needs have been extensively researched; however, a previous Joanna Briggs Institute (JBI) systematic review was the first published systematic review recommending effective interventions for addressing family needs of critically ill patients in an acute intensive care setting. Since its publication in 2011, additional research findings have been published and it was deemed appropriate to update the original systematic review.

OBJECTIVES

This systematic review aims to establish recent best practice in addressing the needs of family members with a relative or loved one admitted to an adult critical care unit.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Studies that included family members (including children) of adult patients in an ICU were considered for inclusion in this review. Patients with any clinical condition, length of stay or outcome were included.

TYPES OF INTERVENTION(S)

This review considered interventions that addressed the five previously identified categories of family needs: support - support groups, training in coping strategies and journal or diary writing; assurance - face-to-face meetings and participation in ward rounds; proximity - changes to visitation policies; information - staff and/or family education, handouts and brochures and the use of technology (e.g. SMS messages); and comfort - changes to the ICU physical environment.

TYPES OF STUDIES

This review considered any randomized controlled trials (RCTs) that evaluated the effectiveness of interventions in addressing family needs of critically ill patients in an adult ICU. In the absence of RCTs, other research designs such as quasi-experimental, as well as pre- and post-studies were considered for inclusion in the narrative summary to enable the identification of current approaches and possible future strategies for addressing family needs of critically ill patients.

TYPES OF OUTCOMES

This review considered studies that evaluated outcomes with a validated tool that measured information comprehension, coping mechanisms, anxiety, depression, stress and satisfaction.

SEARCH STRATEGY

An extensive search of the major databases was conducted. Databases searched included PubMed, CINAHL, psycINFO, Health source, Web of Science, EMBASE, the Cochrane Library and Database of Abstracts of Reviews of Effects. The original search of this review included published and unpublished studies and articles in English from 1980 to 2010. The updated search identified articles for inclusion from 2010 to 2014.

METHODOLOGICAL QUALITY

Quantitative articles selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer.

DATA EXTRACTION

Data was extracted from the articles included in this review using standardized data extraction tools from the JBI Meta Analysis of Statistics Assessment and Review Instrument package.

DATA SYNTHESIS

The studies included in this review were not suitable for meta-analysis and therefore the results are presented as a narrative summary.

RESULTS

Originally, 14 studies and one dissertation met the inclusion criteria and were included in the review. Of these, 12 were quasi-experimental studies and three were prospective randomized trials. In this current update, 14 new articles were identified for inclusion - one RCT, 10 quasi-experimental studies and three observational studies. The settings were in ICUs in Sweden, USA, United Kingdom, the Netherlands, France, Hong Kong, Saudi Arabia and Iran. The evidence identified from all studies in the review includes the use of support groups for family members of patients admitted to an ICU, structured communication and/or education programs for family members, the use of leaflets or brochures to meet family information needs, use of a diary, changes in the physical environment and open or more flexible visiting hours.

CONCLUSIONS

This current update of the original review makes several reiterative and new recommendations for clinical practice to address family needs of patients admitted to a critical care unit; however, the need for significant further research in this area is again highlighted. Future intervention studies focusing on family needs could include the use of technology such as DVDs (Digital Versatile Discs) and SMS (Short Message Service) for informing families and interventions specifically designed to improve family comfort.

IMPLICATIONS FOR PRACTICE

Communication interventions help promote family involvement in their loved one's care and facilitate their decision-making capacity, as well as improving clinician and family interaction, family comprehension of their loved one's condition and also reduce the development of post-traumatic stress-related symptoms (Grade A). Family satisfaction may be increased with the provision of comfortable physical environments with noise reduction measures (Grade B).

IMPLICATIONS FOR RESEARCH

More rigorous high-quality studies investigating interventions to meet the needs of family with a relative in ICU are needed. The majority of included studies in this updated review focused on family satisfaction wherein more robust data on family needs would better inform health professionals in their practice.

Should We Use the IMPACT-Model for the Outcome Prognostication of TBI Patients? A Qualitative Study Assessing Physicians' Perceptions

Introduction. Shared Decision-Making may facilitate information exchange, deliberation, and effective decision-making, but no decision aids currently exist for difficult decisions in neurocritical care patients. The International Patient Decision Aid Standards, a framework for the creation of high-quality decision aids (DA), recommends the presentation of numeric outcome and risk estimates. Efforts are underway to create a goals-of-care DA in critically-ill traumatic brain injury (ciTBI) patients. To inform its content, we examined physicians’ perceptions, and use of the IMPACT-model, the most widely validated ciTBI outcome model, and explored physicians’ preferences for communicating prognostic information towards families. Methods. We conducted a qualitative study using semi-structured interviews in 20 attending physicians (neurosurgery,neurocritical care,trauma,palliative care) at 7 U.S. academic medical centers. We used performed qualitative content analysis of transcribed interviews to identify major themes. Results. Only 12 physicians (60%) expressed awareness of the IMPACT-model; two stated that they “barely” knew the model. Seven physicians indicated using the model at least some of the time in clinical practice, although none used it exclusively to derive a patient’s prognosis. Four major themes emerged: the IMPACT-model is intended for research but should not be applied to individual patients; mistrust in the IMPACT-model derivation data; the IMPACT-model is helpful in reducing prognostic variability among physicians; concern that statistical models may mislead families about a patient’s prognosis. Discussion: Our study identified significant variability of the awareness, perception, and use of the IMPACT-model among physicians. While many physicians prefer to avoid conveying numeric prognostic estimates with families using the IMPACT-model, several physicians thought that they “ground” them and reduce prognostic variability among physicians. These findings may factor into the creation and implementation of future ciTBI-related DAs.

Clinical Momentum in the Intensive Care Unit. A Latent Contributor to Unwanted Care

Many older adults in the United States receive invasive medical care near the end of life, often in an intensive care unit (ICU). However, most older adults report preferences to avoid this type of medical care and to prioritize comfort and quality of life near death. We propose a novel term, "clinical momentum," to describe a system-level, latent, previously unrecognized property of clinical care that may contribute to the provision of unwanted care in the ICU. The example of chronic critical illness illustrates how clinical momentum is generated and propagated during the care of patients with prolonged illness. The ICU is an environment that is generally permissive of intervention, and clinical practice norms and patterns of usual care can promote the accumulation of multiple interventions over time. Existing models of medical decision-making in the ICU describe how individual signs, symptoms, or diagnoses automatically lead to intervention, bypassing opportunities to deliberate about the value of an intervention in the context of a patient's likely outcome or treatment preferences. We hypothesize that clinical momentum influences patients, families, and physicians to accept or tolerate ongoing interventions without consideration of likely outcomes, eventually leading to the delivery of unwanted care near the end of life. In the future, a mixed-methods research program could refine the conceptual model of clinical momentum, measure its impact on clinical practice, and interrupt its influence on unwanted care near the end of life.

End-of-Life Decision Support in the ICU: Where Are We Now?

Determining effective decision support strategies that enhance quality of end-of-life decision making in the intensive care unit is a research priority. This systematic review identified interventional studies describing the effectiveness of decision support interventions administered to critically ill patients or their surrogate decision makers. We conducted a systematic literature search using PubMed, CINAHL, and Cochrane. Our search returned 121 articles, 22 of which met the inclusion criteria. The search generated studies with significant heterogeneity in the types of interventions evaluated and varied patient and surrogate decision-maker outcomes, which limited the comparability of the studies. Few studies demonstrated significant improvements in the primary outcomes. In conclusion, there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers. Additional research is needed to develop and evaluate innovative decision support interventions for end-of-life decision making in the intensive care unit.

The Trial of Ascertaining Individual Preferences for Loved Ones' Role in End-of-Life Decisions (TAILORED) Study: A Randomized Controlled Trial to Improve Surrogate Decision Making

CONTEXT

Patients with terminal illnesses often require surrogate decision makers. Prior research has demonstrated high surrogate stress, and that despite standards promoting substituted judgment, most patients do not want their surrogates to make pure substituted judgments for them. It is not known how best to help loved ones fulfill the surrogate role.

OBJECTIVES

To test the effectiveness of an intervention to help surrogate decision makers.

METHODS

One hundred sixty-six patients (41% with amyotrophic lateral sclerosis and 59% with gastrointestinal cancers) and their surrogates at two university medical centers were randomized to an intensive nurse-directed discussion of the end-of-life decision control preferences of the patient (TAILORED) or a discussion of nutrition (CONTROL); 163 completed baseline interviews and underwent the intervention.

RESULTS

Twelve patients died during follow-up and 137 dyads completed the study. Post-intervention, using all available data, TAILORED patients and surrogates became more likely to endorse mutual surrogate decision making, that is, a balance of their own wishes and what the surrogate thinks best (adjusted odds compared with baseline for patients = 1.78, P = 0.04; adjusted odds for surrogates = 2.05, P = 0.03). CONTROL patients became 40% less likely to endorse mutual surrogate decision making (P = 0.08), and CONTROL surrogates did not change significantly from baseline (adjusted odds = 1.44, P = 0.28). Stress levels decreased for TAILORED surrogates (impact of events scale = 23.1 ± 14.6 baseline, 20.8 ± 15.3 f/u, P = 0.046), but not for CONTROL (P = 0.85), and post-intervention stress was lower for TAILORED than CONTROL (P = 0.04). Surrogates' confidence was uniformly high at baseline and did not change. Caregiver burden (Zarit) increased from 12.5 ± 6.5 to 14.7 ± 8.1 for TAILORED (P < 0.01), while not changing for CONTROL, yet satisfaction with involvement in decision making was higher at follow-up for TAILORED than for CONTROL (71% vs. 52%, P = 0.03).

CONCLUSION

TAILORED patients and surrogates who completed the study adopted a more mutual decision-making style, balancing their own wishes with what the surrogate thinks would be best for them. Surrogates reported less stress and more satisfaction. Confidence was high at baseline and did not change. There was a modest increase in caregiver burden. These findings suggest that interventions like TAILORED might positively impact surrogate decision making.

Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study

OBJECTIVE

Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States.

DESIGN

In a retrospective cohort study, we identified mechanically ventilated patients with the most common causes of respiratory failure leading to tracheostomy: pneumonia/sepsis and trauma. "Early tracheostomy" was performed within the first week of mechanical ventilation. We determined between-hospital variation in early tracheostomy utilization and the association of early tracheostomy with patient outcomes using hierarchical regression.

SETTING

2012 National Inpatient Sample.

PATIENTS

A total of 6,075 pneumonia/sepsis patients and 12,030 trauma patients with tracheostomy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Trauma patients were twice as likely as pneumonia/sepsis patients to receive early tracheostomy (44.5% vs 21.7%; p < 0.001). Admission to hospitals with higher early tracheostomy-to-total-tracheostomy ratios was associated with increased risk for tracheostomy among mechanically ventilated trauma patients (adjusted odds ratio = 1.04; 95% CI, 1.01-1.07) but not pneumonia/sepsis (adjusted odds ratio =1.00; 95% CI, 0.98-1.02). We observed greater between-hospital variation in early tracheostomy rates among trauma patients (21.9-81.9%) compared with pneumonia/sepsis (14.9-38.3%; p < 0.0001). We found no evidence of improved hospital mortality. Pneumonia/sepsis patients with early tracheostomy had fewer feeding tube procedures and higher odds of discharge home.

CONCLUSION

Early tracheostomy is potentially overused among mechanically ventilated trauma patients, with nearly half of tracheostomies performed within the first week of mechanical ventilation and large unexplained hospital variation, without clear benefits. Future studies are needed to characterize potentially differential benefits for early tracheostomy between disease subgroups and to investigate factors driving hospital variation in tracheostomy timing.