Leslie P Scheunemann1,2, Natalie C Ernecoff3, Praewpannarai Buddadhumaruk4, Shannon S Carson5, Catherine L Hough6, J Randall Curtis6,7, Wendy G Anderson8,9,10, Jay Steingrub11, Bernard Lo12, Michael Matthay13, Robert M Arnold14,15, Douglas B White4. 1. Division of Geriatric Medicine and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania. 2. Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. 3. Department of Health Policy and Management, University of North Carolina at Chapel Hill. 4. Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. 5. Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill. 6. Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle. 7. Cambia Palliative Care Center of Excellence, University of Washington, Seattle. 8. Palliative Care Program, University of California, San Francisco Medical Center, San Francisco. 9. Division of Hospital Medicine, University of California, San Francisco School of Medicine, San Francisco. 10. Department of Physiological Nursing, University of California, San Francisco School of Nursing, San Francisco. 11. Division of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield. 12. The Greenwall Foundation, New York, New York. 13. Departments of Medicine and Anesthesia and Perioperative Care, University of California, San Francisco. 14. Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania. 15. Palliative and Supportive Institute, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania.
Abstract
Importance: Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating intensive care unit (ICU) patients' values and preferences into treatment decisions. Objectives: To determine how often clinicians and surrogates exchange information about patients' previously expressed values and preferences and deliberate and plan treatment based on these factors during conferences about prognosis and goals of care for incapacitated ICU patients. Design, Setting, and Participants: A secondary analysis of a prospective, multicenter cohort study of audiorecorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults was conducted. The study was performed between October 8, 2009, and October 23, 2012. Data analysis was performed between July 2, 2014, and April 20, 2015. Patient eligibility criteria included lack of decision-making capacity, a diagnosis of acute respiratory distress syndrome, and predicted in-hospital mortality of 50% or more. In addition to the patients, 451 surrogates and 144 clinicians at 13 ICUs at 6 US academic and community medical centers were included. Main Outcomes and Measures: Two coders analyzed transcripts of audiorecorded conversations for statements in which clinicians and surrogates exchanged information about patients' treatment preferences and health-related values and applied them in deliberation and treatment planning. Results: Of the 249 patients, 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%; 95% CI, 20.3%-31.3%) contained no information exchange or deliberation about patients' values and preferences. Clinicians and surrogates exchanged information about patients' values and preferences in 167 (68.4%) (95% CI, 62.6%-74.3%) of the conferences and specifically deliberated about how the patients' values applied to the decision in 108 (44.3%; 95% CI, 38.0%-50.5%). Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 87 (35.7%) or less of the conferences; surrogates provided a substituted judgment in 33 (13.5%); and clinicians made treatment recommendations based on patients' values and preferences in 20 conferences (8.2%). Conclusions and Relevance: Most clinician-family conferences about prognosis and goals of care for critically ill patients appear to lack important elements of communication about values and preferences, with robust deliberation being particularly deficient. Interventions may be needed to better prepare surrogates for these conversations and improve clinicians' communication skills for eliciting and incorporating patients' values and preferences into treatment decisions.
Importance: Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating intensive care unit (ICU) patients' values and preferences into treatment decisions. Objectives: To determine how often clinicians and surrogates exchange information about patients' previously expressed values and preferences and deliberate and plan treatment based on these factors during conferences about prognosis and goals of care for incapacitated ICU patients. Design, Setting, and Participants: A secondary analysis of a prospective, multicenter cohort study of audiorecorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults was conducted. The study was performed between October 8, 2009, and October 23, 2012. Data analysis was performed between July 2, 2014, and April 20, 2015. Patient eligibility criteria included lack of decision-making capacity, a diagnosis of acute respiratory distress syndrome, and predicted in-hospital mortality of 50% or more. In addition to the patients, 451 surrogates and 144 clinicians at 13 ICUs at 6 US academic and community medical centers were included. Main Outcomes and Measures: Two coders analyzed transcripts of audiorecorded conversations for statements in which clinicians and surrogates exchanged information about patients' treatment preferences and health-related values and applied them in deliberation and treatment planning. Results: Of the 249 patients, 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%; 95% CI, 20.3%-31.3%) contained no information exchange or deliberation about patients' values and preferences. Clinicians and surrogates exchanged information about patients' values and preferences in 167 (68.4%) (95% CI, 62.6%-74.3%) of the conferences and specifically deliberated about how the patients' values applied to the decision in 108 (44.3%; 95% CI, 38.0%-50.5%). Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 87 (35.7%) or less of the conferences; surrogates provided a substituted judgment in 33 (13.5%); and clinicians made treatment recommendations based on patients' values and preferences in 20 conferences (8.2%). Conclusions and Relevance: Most clinician-family conferences about prognosis and goals of care for critically illpatients appear to lack important elements of communication about values and preferences, with robust deliberation being particularly deficient. Interventions may be needed to better prepare surrogates for these conversations and improve clinicians' communication skills for eliciting and incorporating patients' values and preferences into treatment decisions.
Authors: Peter H Ditto; Jennifer A Druley; Kathleen A Moore; Joseph H Danks; William D Smucker Journal: Health Psychol Date: 1996-09 Impact factor: 4.267
Authors: Leslie P Scheunemann; Thomas V Cunningham; Robert M Arnold; Praewpannarai Buddadhumaruk; Douglas B White Journal: Crit Care Med Date: 2015-04 Impact factor: 7.598
Authors: Margaret S Herridge; Catherine M Tansey; Andrea Matté; George Tomlinson; Natalia Diaz-Granados; Andrew Cooper; Cameron B Guest; C David Mazer; Sangeeta Mehta; Thomas E Stewart; Paul Kudlow; Deborah Cook; Arthur S Slutsky; Angela M Cheung Journal: N Engl J Med Date: 2011-04-07 Impact factor: 91.245
Authors: J Randall Curtis; Ruth A Engelberg; Marjorie D Wenrich; Sarah E Shannon; Patsy D Treece; Gordon D Rubenfeld Journal: Am J Respir Crit Care Med Date: 2005-01-07 Impact factor: 21.405
Authors: P P Pandharipande; T D Girard; J C Jackson; A Morandi; J L Thompson; B T Pun; N E Brummel; C G Hughes; E E Vasilevskis; A K Shintani; K G Moons; S K Geevarghese; A Canonico; R O Hopkins; G R Bernard; R S Dittus; E W Ely Journal: N Engl J Med Date: 2013-10-03 Impact factor: 91.245
Authors: Emilio Sacanella; Joan Manel Pérez-Castejón; Josep Maria Nicolás; Ferran Masanés; Marga Navarro; Pedro Castro; Alfonso López-Soto Journal: Crit Care Date: 2011-03-28 Impact factor: 9.097
Authors: Charlotte Gerrity; Samantha Farley; Mary C Barks; Peter A Ubel; Debra Brandon; Kathryn I Pollak; Monica E Lemmon Journal: J Child Neurol Date: 2022-02-08 Impact factor: 2.363
Authors: Heather Coats; Paula M Meek; Lisa M Schilling; Terrah Foster Akard; Ardith Z Doorenbos Journal: J Palliat Med Date: 2020-01-06 Impact factor: 2.947
Authors: Spyros D Mentzelopoulos; Keith Couper; Patrick Van de Voorde; Patrick Druwé; Marieke Blom; Gavin D Perkins; Ileana Lulic; Jana Djakow; Violetta Raffay; Gisela Lilja; Leo Bossaert Journal: Notf Rett Med Date: 2021-06-02 Impact factor: 0.826