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Wittenberg E, Goldsmith JV, Chen C(K, Prince-Paul M. A conceptual model of the nurse's role as primary palliative care provider in goals of care communication. PEC INNOVATION 2024; 4:100254. [PMID: 38298557 PMCID: PMC10828588 DOI: 10.1016/j.pecinn.2024.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/10/2023] [Accepted: 01/10/2024] [Indexed: 02/02/2024]
Abstract
Objective Nurses have opportunities to engage in goals of care conversations that can promote palliative care communication. The purpose of this study was to describe nurses' experiences in goals of care communication as summarized in the literature and to present a conceptual model of communication pathways for nurses. Methods An integrative review of the literature (2016-2022) addressing nurses' experiences in goals of care communication was conducted using PubMed, CINAHL, and PsychInfo databases. A total of 92 articles were retrieved. A total of 12 articles were included for this review after applying the inclusion and exclusion criteria. Results Of the 12 articles, the majority were qualitative studies (n = 8). Qualitative analysis of findings from all articles revealed three dominant themes: nurses' ambiguous role responsibilities, goals of care as end-of-life communication, and the need for nurse communication training. Conclusion This article suggests an innovative conceptual model for advancing nurse communication about goals of care to facilitate primary palliative care. Innovation The framework characterizes two communication pathways for Advanced Practice Nurses who direct goals of care discussions and Registered Nurses who support goals of care communication. The model informs future communication training aimed at supporting primary palliative care.
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Affiliation(s)
- Elaine Wittenberg
- From California State University Los Angeles, Department of Communication Studies, Los Angeles, CA, USA
| | - Joy V. Goldsmith
- From University of Memphis, Department of Communication and Film, Memphis, TN, USA
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Kelly D, Barrett J, Brand G, Leech M, Rees C. Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review. Aust Crit Care 2024; 37:805-817. [PMID: 38609749 DOI: 10.1016/j.aucc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. AIM The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. DESIGN Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. METHODS Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. RESULTS Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. CONCLUSION Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.
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Affiliation(s)
- Diane Kelly
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia.
| | - Jonathan Barrett
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia
| | - Gabrielle Brand
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Frankston, VIC, Australia
| | - Michelle Leech
- Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Charlotte Rees
- Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; School of Health Sciences, College of Medicine, Nursing & Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
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Lanocha N, Taub S, Webb JA, Wood M, Tate T. It Starts With a Story: A Four-Step Narrative-Based Framework for Serious Illness Conversations. J Palliat Med 2024. [PMID: 38968377 DOI: 10.1089/jpm.2024.0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024] Open
Abstract
Background: As a key component of advance care planning, serious illness conversations form a core intervention in palliative care. To achieve effective serious illness conversations, acknowledgment and inclusion of patient sense of self and identity are critical. However, no framework exists to describe how goals, values, and choices relate to patient identity. This conceptual gap hinders the advancement of palliative care education and practice. Objective: This philosophical investigation aimed to explicate two items: first, a novel conceptual framework for serious illness conversations; second, a structured approach to optimize these conversations within the palliative care clinical context. Methods: A philosophical and theoretical analysis was performed within an interdisciplinary context, by scholars in palliative care, medical humanities, philosophy, and bioethics. Key literature in psychology, qualitative research on the experience of serious illness, medical ethics, and choice architecture in medical decision-making were reviewed, and a structured conceptual and narrative analysis was performed. Results: An original and innovative identity-centered conceptual framework for serious illness conversations was developed. The framework consists of a four-step, reproducible approach: (1) attend to patient narrative identity, (2) identify values, (3) cocreate goals, and (4) actively promote choices. In short: attend, identify, create, and promote (AICP). Discussion: By using this conceptual framework and four-step approach, clinicians can accomplish goal-concordant serious illness care and build rich clinical relationships that foster trust and goodwill.
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Affiliation(s)
| | - Sara Taub
- Knight Cancer Institute, Portland, Oregon, USA
| | - Jason A Webb
- Oregon Health and Science University, Portland, Oregon, USA
- University of Oregon, Eugene, Oregon, USA
| | - Mary Wood
- University of Oregon, Eugene, Oregon, USA
| | - Tyler Tate
- Stanford University School of Medicine, Palo Alto, California, USA
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Xing Y, Cai W, Wang A, Yuan Y, Zhang R. Effectiveness of decision aids on critically ill patients' outcomes and family members' knowledge, anxiety, depression and decisional conflict: A systematic review and meta-analysis. Nurs Crit Care 2024. [PMID: 38960705 DOI: 10.1111/nicc.13115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 04/29/2024] [Accepted: 06/06/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Decision aids (DAs) have been proposed to support patients and families with disease information processing and decision-making, but their effectiveness for critically ill patients and their families is incompletely understood. AIM To systematically synthesize evidence on the effectiveness of the DAs on the prognosis of critically ill patients and knowledge, anxiety, depression and decisional conflict of their family members. STUDY DESIGN Systematic review and meta-analysis. We conducted a systematic search of literature using PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature database, Scopus, PsycNet, CNKI and Wanfang Database from the inception of the databases until May 2023 to identify randomized clinical trials (RCTs) describing DAs interventions targeted at adult intensive care unit (ICU) patients or their families. We also searched grey literature in four databases: Chinese Clinical Trials Registry, Chinese Cochrane Center, Open Grey and GreyNet International. RESULTS Seven RCTs were included in the review. Meta-analysis identified longer hospital length of stay (LOS) among all patients compared with usual care (mean difference [MD] = 5.64 days, 95% confidence interval, CI [0.29, 10.98], p = .04), but not in surviving patients (MD = 2.09 days, 95% CI [-3.70, 7.89], p = .48). However, there was no evidence of an effect of DAs on hospital mortality (RR = 1.25, 95% CI [0.92, 1.70], p = .15), ICU LOS (MD = 3.77 days, 95% CI [-0.17, 7.70], p = .06) and length of mechanical ventilation (MD = 0.88 days, 95% CI [-2.22, 3.97], p = .58). DAs led to a statistically significant improvement in family members' knowledge (standard mean difference = 0.84, 95% CI [0.12, 1.56], p = .02). We found no significant effect of DAs on anxiety, depression, post-traumatic stress disorder, decisional conflict and quality of communication of family members. CONCLUSIONS This review provides effective evidence that DAs can potentially improve the knowledge level of family members while prolonging the hospital LOS among critically ill patients. RELEVANCE TO CLINICAL PRACTICE Well-designed large-scale studies with DAs tailored to the individuals' preferences and existing cultural values are warranted.
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Affiliation(s)
- Yana Xing
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weixin Cai
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuan Yuan
- Intensive Care Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ran Zhang
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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5
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Hart JL, Malik L, Li C, Summer A, Ogunduyile L, Steingrub J, Lo B, Zlatev J, White DB. Clinicians' Use of Choice Framing in ICU Family Meetings. Crit Care Med 2024:00003246-990000000-00349. [PMID: 38912880 DOI: 10.1097/ccm.0000000000006360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
OBJECTIVES To quantify the frequency and patterns of clinicians' use of choice frames when discussing preference-sensitive care with surrogate decision-makers in the ICU. DESIGN Secondary sequential content analysis. SETTING One hundred one audio-recorded and transcribed conferences between surrogates and clinicians of incapacitated, critically ill adults from a prospective, multicenter cohort study. SUBJECTS Surrogate decision-makers and clinicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four coders identified preference-sensitive decision episodes addressed in the meetings, including topics such as mechanical ventilation, renal replacement, and overall goals of care. Prior critical care literature provided specific topics identified as preference-sensitive specific to the critical care context. Coders then examined each decision episode for the types of choice frames used by clinicians. The choice frames were selected a priori based on decision science literature. In total, there were 202 decision episodes across the 101 transcripts, with 20.3% of the decision episodes discussing mechanical ventilation, 19.3% overall goals of care, 14.4% renal replacement therapy, 14.4% post-discharge care (i.e., discharge location such as a skilled nursing facility), and the remaining 32.1% other topics. Clinicians used default framing, in which an option is presented that will be carried out if another option is not actively chosen, more frequently than any other choice frame (127 or 62.9% of decision episodes). Clinicians presented a polar interrogative, or a "yes or no question" to accept or reject a specific care choice, in 43 (21.3%) decision episodes. Clinicians more frequently presented options emphasizing both potential losses and gains rather than either in isolation. CONCLUSIONS Clinicians frequently use default framing and polar questions when discussing preference-sensitive choices with surrogate decision-makers, which are known to be powerful nudges. Future work should focus on designing interventions promoting the informed use of these and the other most common choice frames used by practicing clinicians.
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Affiliation(s)
- Joanna L Hart
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Leena Malik
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
| | - Carrie Li
- Department of Neurology, Massachusetts General Hospital and Brigham Women's Hospital, Harvard University, Boston, MA
| | - Amy Summer
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
| | - Lon Ogunduyile
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
| | - Jay Steingrub
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Julian Zlatev
- Department of Business Administration, Harvard Business School, Boston, MA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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6
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Hernández-Zambrano SM, Carrillo-Algarra AJ, Manotas-Solano OE, Ibáñez-Gamboa SE, Mejia-Mendez LM, Martínez-Montoya OH, Fernández-Alcántara M, Hueso-Montoro C. Interprofessional interventions and factors that improve end-of-life care in intensive care units: An integratory review. ENFERMERIA INTENSIVA 2024:S2529-9840(23)00069-1. [PMID: 38910066 DOI: 10.1016/j.enfie.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/24/2023] [Indexed: 06/25/2024]
Abstract
INTRODUCTION The changes in health dynamics, caused by the SARS-COVD-2 pandemic and its consequences, generated a greater need to integrate palliative care in the ICU to promote a dignified death. OBJECTIVE Identify interprofessional interventions and factors that improve the care of patients at the end of life. METHODOLOGY Integrative review, including experimental, quasi-experimental, observational, analytical, and descriptive studies with correlation of variables, published from 2010 to 2021, identified in COCHRANE, CINAHL, CUIDEN, LILACS, SCIELO, Dialnet, PsychInfo, PubMed, PROQUES, PSYCHOLOGY, JOURNALS, SCIENCEDIRECT, with MeSH/DECS terms: "Critical Care", "IntensiveCare" "Life support care", "Palliative care", "Life Quality", "Right to die". 36,271 were identified, after excluding duplicate title, abstract, year of publication, design, theme, methodological quality, objectives, and content, 31 studies were found. RESULTS It included 31 articles, 16.7% experimental, 3.3% quasi-experimental, 80% observational, analytical, and descriptive with correlation of variables, 38% published in the United States, 38%, and 19% in Brazil. The pooled sample was 24,779 participants. 32.2% of the studies had level of evidence 1 recommendation (c), and 25.8% level of evidence 2 recommendation (c). This paper synthesises evidence to promote Interprofessional Collaborative Practice in the ICU, improve end-of-life care, and interventions to achieve established therapeutic goals, implement effective care policies, plans, and programmes for critically ill patients and their families; factors that affect palliative care and improve with training and continuing education for health personnel. CONCLUSION There are interventions to manage physical and emotional symptoms, training strategies and emotional support aimed at health personnel and family members to improve the quality of death and reduce stays in the ICU. The interdisciplinary team requires training on palliative and end-of-life care to improve care.
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Affiliation(s)
- S M Hernández-Zambrano
- Grupo Perspectivas del Cuidado, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia.
| | - A J Carrillo-Algarra
- Grupo Perspectivas del Cuidado, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | - O E Manotas-Solano
- Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | - S E Ibáñez-Gamboa
- Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | - L M Mejia-Mendez
- Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | - O H Martínez-Montoya
- Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | | | - C Hueso-Montoro
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Jaén, Instituto de Investigación Biosanitaria de Granada (Ibs.GRANADA), Centro de Investigación Mente, Cerebro y Comportamiento (CIMCYC), Jaén, Spain
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Chinta S, Haleem A, Sibala DR, Kumar KD, Pendyala N, Aftab OM, Choudhry HS, Hegazin M, Eloy JA. Association Between Modified Frailty Index and Postoperative Outcomes of Tracheostomies. Otolaryngol Head Neck Surg 2024; 170:1307-1313. [PMID: 38329229 DOI: 10.1002/ohn.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The 5-item modified frailty index (mFI-5) has been used to stratify patients based on the risk of postoperative complications in several surgical procedures but has not yet been done in tracheostomies. This study investigates the association between the mFI-5 score and tracheostomy complications. STUDY DESIGN Retrospective database review. SETTING United States hospitals. METHODS The National Surgical Quality Improvement Program database was queried for tracheostomy patients between 2005 and 2018. The mFI-5 was calculated for each patient by assigning 1 point for each of the following comorbidities: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Univariate and multivariable analyses were conducted to determine associations between the mFI-5 score and postoperative complications. RESULTS A total of 4438 patients undergoing tracheostomies were queried and stratified into the following groups: mFI = 0 (N = 1741 [39.2%], mFI = 1 (N = 1720 [38.8%]), mFI = 2 (N = 726 [16.4%]), and mFI of 3 or higher (N = 251 [5.7%]). Univariate analysis showed that patients with higher mFI-5 scores had a greater proportion of smoking, dyspnea, obesity, steroid use, emergency cases, complications, reoperations, and mortality (P < .001). Multivariable analyses found associations between mFI-5 score and any complication (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03-2.16, P = .035), mortality (OR: 2.32, 95% CI: 1.15-4.68, P = .019), and any medical complication (OR: 2.75, 95% CI: 1.88-4.02, P < .001). CONCLUSION This study suggests an association between the mFI-5 score and postoperative complications in tracheostomies. mFI-5 score can be used to stratify tracheostomy patients by operative risk.
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Affiliation(s)
- Sree Chinta
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Afash Haleem
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Dhiraj R Sibala
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Keshav D Kumar
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Navya Pendyala
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Owais M Aftab
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Hannaan S Choudhry
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Michael Hegazin
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic, Surgery, Saint Barnabas Medical Center-RWJBarnabas Health, Livingston, New Jersey, USA
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Sun WN, Kao CY. The Challenges in Using eHealth Decision Resources for Surrogate Decision-Making in the Intensive Care Unit. J Med Internet Res 2024; 26:e47017. [PMID: 38557504 PMCID: PMC11019413 DOI: 10.2196/47017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 11/23/2023] [Accepted: 01/29/2024] [Indexed: 04/04/2024] Open
Abstract
The mortality rate in intensive care units (ICUs) is notably high, with patients often relying on surrogates for critical medical decisions due to their compromised state. This paper provides a comprehensive overview of eHealth. The challenges of applying eHealth tools, including economic disparities and information inaccuracies are addressed. This study then introduces eHealth literacy and the assessment tools to evaluate users' capability and literacy levels in using eHealth resources. A clinical scenario involving surrogate decision-making is presented. This simulated case involves a patient with a hemorrhagic stroke who has lost consciousness and requires medical procedures such as tracheostomy. However, due to the medical surrogate's lack of familiarity with eHealth devices and limited literacy in using eHealth resources, difficulties arise in assisting the patient in making medical decisions. This scenario highlights challenges related to eHealth literacy and solution strategies are proposed. In conclusion, effective ICU decision-making with eHealth tools requires a careful balance between efficiency with inclusivity. Tailoring communication strategies and providing diverse materials are essential for effective eHealth decision resources in the ICU setting. Health professionals should adopt a patient-centered approach to enhance the decision-making experience, particularly for individuals with limited eHealth literacy.
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Affiliation(s)
- Wan-Na Sun
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Yin Kao
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Van Scoy LJ, Scott AM, Higgins J, Wasserman E, Heyland D, Chinchilli V, Green MJ. Feasibility and Acceptability of a Novel Intensive Care Unit Communication Intervention ("Let's Talk") and Initial Assessment Using the Multiple Goals Theory of Communication. Am J Hosp Palliat Care 2024; 41:373-382. [PMID: 37173285 PMCID: PMC10885768 DOI: 10.1177/10499091231176296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Abstract
Background: Family members of intensive care unit (ICU) patients often report poor communication, feeling unprepared for ICU family meetings, and poor psychological outcomes after decision-making. The objective of this study was to create a tool to prepare families for ICU family meetings and assess feasibility of using Communication Quality Analysis (CQA) to measure communication quality of family meetings. Methods: This observational study was conducted at an academic tertiary care center in Hershey, PA from March 2019 to 2020. Phase 1a involved conceptual design. Phase 1b entailed acceptability testing of 2 versions of the tool (text-only, comic) with 9 family members of non-capacitated ICU patients; thematic analysis of semi-strucutred interviews was conducted. Phase 1c assessed feasibility of applying CQA to audio-recorded ICU family meetings (n = 17); 3 analysts used CQA to assess 6 domains of communication quality. Wilcoxon Signed Rank tests were used to interpret CQA scores. Results: Four themes emerged from Phase 1b interviews: participants 1) found the tool useful for meeting preparation and organizing thoughts, 2) appreciated emotional content, 3) preferred the comic form (67%), and 4) had indifferent or negative perceptions about specific elements. In Phase 1c, clinicians scored higher on the CQA content and engagement domains; family members scored higher on the emotion domain. CQA scores in the relationship and face domains had the lowest quality ratings. Conclusions: Let's Talk may help families become better prepared for ICU family meetings. CQA provides a feasible approach to assessing communication quality that identifies specific areas of strengths and weaknesses in communication.
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Affiliation(s)
- Lauren J Van Scoy
- Departments of Medicine, Humanities and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Allison M Scott
- Department of Communication, University of Kentucky, Lexington, KY, USA
| | - Jacob Higgins
- Department of Nursing Professional Practice and Development, University of Kentucky College of Nursing and UK Healthcare, Lexington, KY, USA
| | - Emily Wasserman
- Departments of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Daren Heyland
- Department of Critical Care Medicine, Queens University, Kingston, ON, Canada
| | - Vernon Chinchilli
- Departments of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Michael J Green
- Departments of Medicine and Humanities, Penn State College of Medicine, Hershey, PA, USA
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10
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Geurtzen R, Wilkinson DJC. Incorporating parental values in complex paediatric and perinatal decisions. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:225-235. [PMID: 38219752 DOI: 10.1016/s2352-4642(23)00267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 01/16/2024]
Abstract
Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.
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Affiliation(s)
- Rosa Geurtzen
- Amalia Children's Hospital, Radboud Institute of Healthcare Sciences, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Dominic J C Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; Oxford Newborn Care Unit, John Radcliffe Hospital, Oxford University, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore
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11
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Renckens SC, Pasman HR, Jorna Z, Klop HT, Perron CD, van Zuylen L, Steegers MAH, Ten Tusscher BL, van Mol MMC, Vloet LCM, Onwuteaka-Philipsen BD. Varying (preferred) levels of involvement in treatment decision-making in the intensive care unit before and during the COVID-19 pandemic: a mixed-methods study among relatives. BMC Med Inform Decis Mak 2024; 24:46. [PMID: 38347583 PMCID: PMC10863197 DOI: 10.1186/s12911-024-02429-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/16/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND In the intensive care unit (ICU) relatives play a crucial role as surrogate decision-makers, since most patients cannot communicate due to their illness and treatment. Their level of involvement in decision-making can affect their psychological well-being. During the COVID-19 pandemic, relatives' involvement probably changed. We aim to investigate relatives' involvement in decision-making in the ICU before and during the pandemic and their experiences and preferences in this regard. METHODS A mixed-methods study among relatives of ICU patients admitted to an ICU before or during the COVID-19 pandemic. Relatives in six ICUs completed a questionnaire (n = 329), including two items on decision-making. These were analysed using descriptive statistics and logistic regression analyses. Subsequently, relatives (n = 24) were interviewed about their experiences and preferences regarding decision-making. Thematic analysis was used for analysing the qualitative data. RESULTS Nearly 55% of the relatives indicated they were at least occasionally asked to be involved in important treatment decisions and of these relatives 97.1% reported to have had enough time to discuss questions and concerns when important decisions were to be made. During the first COVID-19 wave relatives were significantly less likely to be involved in decision-making compared to relatives from pre-COVID-19. The interviews showed that involvement varied from being informed about an already made decision to deliberation about the best treatment option. Preferences for involvement also varied, with some relatives preferring no involvement due to a perceived lack of expertise and others preferring an active role as the patient's advocate. Discussing a patient's quality of life was appreciated by relatives, and according to relatives healthcare professionals also found this valuable. In some cases the preferred and actual involvement was in discordance, preferring either a larger or a smaller role. CONCLUSIONS As treatment alignment with a patient's values and preferences and accordance between preferred and actual involvement in decision-making is very important, we suggest that the treatment decision-making process should start with discussions about a patient's quality of life, followed by tailoring the process to relatives' preferences as much as possible. Healthcare professionals should be aware of relatives' heterogeneous and possibly changing preferences regarding the decision-making process.
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Affiliation(s)
- Sophie C Renckens
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands.
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands.
| | - H Roeline Pasman
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Zina Jorna
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Hanna T Klop
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Viaa University of Applied Sciences, Zwolle, The Netherlands
| | - Chantal du Perron
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Lia van Zuylen
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, location VU Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Monique A H Steegers
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
| | - Birkitt L Ten Tusscher
- Department of Intensive Care Medicine, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
| | - Margo M C van Mol
- Erasmus MC, Department of Intensive Care Medicine Adults, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Foundation Family and patient Centered Intensive Care (FCIC), Alkmaar, The Netherlands
| | - Lilian C M Vloet
- Foundation Family and patient Centered Intensive Care (FCIC), Alkmaar, The Netherlands
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
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12
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Kruser JM, Ashana DC, Courtright KR, Kross EK, Neville TH, Rubin E, Schenker Y, Sullivan DR, Thornton JD, Viglianti EM, Costa DK, Creutzfeldt CJ, Detsky ME, Engel HJ, Grover N, Hope AA, Katz JN, Kohn R, Miller AG, Nabozny MJ, Nelson JE, Shanawani H, Stevens JP, Turnbull AE, Weiss CH, Wirpsa MJ, Cox CE. Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2024; 21:187-199. [PMID: 38063572 PMCID: PMC10848901 DOI: 10.1513/annalsats.202310-925st] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.
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13
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Mead G. Shared decision making in older people after severe stroke. Age Ageing 2024; 53:afae017. [PMID: 38364821 DOI: 10.1093/ageing/afae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Indexed: 02/18/2024] Open
Abstract
Stroke is a major cause of death and lifelong disability. Although stroke treatments have improved, many patients are left with life-changing deficits. Shared decision making and consent are fundamental to good medical practice. This is challenging because stroke often causes mental incapacity, prior views might not be known and prognosis early after stroke is often uncertain. There are no large trials of shared decision making after severe stroke, so we need to rely on observational data to inform practice. Core ethical principles of autonomy, beneficence, non-maleficence and justice must underpin our decision making. 'Surrogate' decision makers will need to be involved if a patient lacks capacity, and prior expressed views and values and beliefs need to be taken into account in decision making. Patients and surrogates often feel shocked at the sudden nature of stroke, and experience grief including anticipatory grief. Health care professionals need to acknowledge these feelings and provide support, be clear about what decisions need to be made and provide sufficient information about the stroke, and the risks and benefits of treatments being considered. Shared decision making can be emotionally difficult for health care professionals and so working in a supportive environment with compassionate leadership is important. Further research is needed to better understand the nature of grief and what sort of psychological support would be most helpful. Large randomised trials of shared decision making are also needed.
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Affiliation(s)
- Gillian Mead
- Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh EH16 4SA, UK
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14
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Hendershot KA, Elias MN, Taylor BL, Wahlster S, Creutzfeldt CJ. An Update on Palliative Care in Neurocritical Care: Providing Goal‑Concordant Care in the Face of Prognostic Uncertainty. Curr Treat Options Neurol 2023; 25:517-529. [PMID: 39055121 PMCID: PMC11271663 DOI: 10.1007/s11940-023-00778-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 07/27/2024]
Abstract
Purpose of review We investigate the complexities and interplay between the concepts of prognostic uncertainty and patient preferences as they relate to the delivery of goal-concordant care to patients with severe acute brain injuries (SABI) in the Neurological Intensive Care Unit (Neuro-ICU). Recent findings Patients with SABI in the Neuro-ICU have unique palliative care needs due to sudden, often unexpected changes in personhood and quality of life. A substantial amount of uncertainty is inherent and poses a challenge to both the patient's prognosis and treatment preferences. The delivery of goal-concordant care can be difficult to achieve.
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Affiliation(s)
- Kristopher A. Hendershot
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Maya N. Elias
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Breana L. Taylor
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Claire J. Creutzfeldt
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, 325 9th Avenue, Box 359775, Seattle, WA 98104‑2499, USA
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15
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Mittal V, Hakes NA, Magnus D, Batten JN. Vagueness in Goals-of-Care Conferences for Critically Ill Patients: Types of Hedge Language Used by Physicians. Crit Care Med 2023; 51:1538-1546. [PMID: 37358354 DOI: 10.1097/ccm.0000000000005974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
OBJECTIVES Hedge language is a category of language that refers to words or phrases that make statements "fuzzier." We sought to understand how physicians use hedge language during goals-of-care conferences in the ICU. DESIGN Secondary analysis of transcripts of audio-recorded goals-of-care conferences in the ICU. SETTING Thirteen ICUs at six academic and community medical centers in the United States. PATIENTS Conferences were between clinicians and surrogates of incapacitated, critically ill adults. INTERVENTIONS Four investigators performed a qualitative content analysis of transcripts using deductive followed by inductive methods to identify types of hedge language used by physicians, then coded all instances of hedge language across 40 transcripts to characterize general patterns in usage. MEASUREMENTS AND MAIN RESULTS We identified 10 types of hedge language: numeric probabilistic statement ("there's an 80% chance"), qualitative probabilistic statement ("there's a good chance"), nonprobabilistic uncertainty statement ("hard to say for her"), plausibility shield ("we expect"), emotion-based statement ("we're concerned"), attribution shield ("according to Dr. X"), adaptor ("sort of"), metaphor ("the chips are stacking up against her"), time reference ("too soon to tell"), and contingency statement ("if we are lucky"). For most types of hedge language, we identified distinct subtypes. Physicians used hedge language frequently in every transcript (median: 74 hedges per transcript) to address diagnosis, prognosis, and treatment. We observed large variation in how frequently each type and subtype of hedge language was used. CONCLUSIONS Hedge language is ubiquitous in physician-surrogate communication during goals-of-care conferences in the ICU and can be used to introduce vagueness to statements in ways beyond expressing uncertainty. It is not known how hedge language impacts decision-making or clinician-surrogate interactions. This study prioritizes specific types of hedge language for future research based on their frequency and novelty.
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Affiliation(s)
- Vaishali Mittal
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- Department of Dermatology, Stanford University, Stanford, CA
| | - Nicholas A Hakes
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - David Magnus
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- Department of Medicine, Stanford University, Stanford, CA
- Department of Pediatrics, Stanford University, Stanford, CA
| | - Jason N Batten
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA
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16
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Göcking B, Gloeckler S, Ferrario A, Brandi G, Glässel A, Biller-Andorno N. A case for preference-sensitive decision timelines to aid shared decision-making in intensive care: need and possible application. Front Digit Health 2023; 5:1274717. [PMID: 37881363 PMCID: PMC10595152 DOI: 10.3389/fdgth.2023.1274717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/28/2023] [Indexed: 10/27/2023] Open
Abstract
In the intensive care unit, it can be challenging to determine which interventions align with the patients' preferences since patients are often incapacitated and other sources, such as advance directives and surrogate input, are integral. Managing treatment decisions in this context requires a process of shared decision-making and a keen awareness of the preference-sensitive instances over the course of treatment. The present paper examines the need for the development of preference-sensitive decision timelines, and, taking aneurysmal subarachnoid hemorrhage as a use case, proposes a model of one such timeline to illustrate their potential form and value. First, the paper draws on an overview of relevant literature to demonstrate the need for better guidance to (a) aid clinicians in determining when to elicit patient preference, (b) support the drafting of advance directives, and (c) prepare surrogates for their role representing the will of an incapacitated patient in clinical decision-making. This first section emphasizes that highlighting when patient (or surrogate) input is necessary can contribute valuably to shared decision-making, especially in the context of intensive care, and can support advance care planning. As an illustration, the paper offers a model preference-sensitive decision timeline-whose generation was informed by existing guidelines and a series of interviews with patients, surrogates, and neuro-intensive care clinicians-for a use case of aneurysmal subarachnoid hemorrhage. In the last section, the paper offers reflections on how such timelines could be integrated into digital tools to aid shared decision-making.
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Affiliation(s)
- Beatrix Göcking
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Sophie Gloeckler
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Andrea Ferrario
- Department of Management, Technology, and Economics, Swiss Federal Institute of Technology in Zurich, Zurich, Switzerland
- Mobiliar Lab for Analytics at ETH, Zurich, Switzerland
| | - Giovanna Brandi
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Andrea Glässel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
- School of Health Sciences, Institute of Public Health, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
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17
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Erickson SG, Siparsky NF. Assessing Communication Quality in the Intensive Care Unit. Am J Hosp Palliat Care 2023; 40:1058-1066. [PMID: 36367851 DOI: 10.1177/10499091221139427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Introduction: Successful shared decision-making for critically ill intensive care unit (ICU) patients requires bidirectional communication. Through observation of ICU conversations, our study aimed to identify communication skill deficiencies in providers who care for patients in the ICU. Methods: This was an observational prospective study performed in a single urban academic medical center (671 beds) from June 2021 through August 2021. Twenty-three providers were recruited from medical and surgical ICU services (56 beds). Thirty-nine surrogate decision makers were identified. Provider skills were assessed using a customized observational tool that examined nonverbal communication, verbal communication, opening the discussion, gathering information, understanding the family's perspective, sharing information, reaching agreements on problems and plans, and providing closure. Results: Thirty-nine conversations were observed for six attending physicians, four fellow physicians, eight resident physicians, two nurse practitioners, and three physician assistants during the coronavirus 19 (COVID19) pandemic. A dedicated critical care provider engaged in 19 observed conversations; 20 discussions occurred with individuals rotating/consulting in the ICU. Communication skill did not depend on experience or area of expertise. Less than half of conversations achieved bidirectional communication proficiency. Scheduled conversations (n = 14) had significantly higher average communication scores than unscheduled encounters (n = 25). Conclusions: Superficial unidirectional communication with decision makers was commonly observed. Providers were less proficient at advanced communication skills needed for shared decision-making. We recommend that providers have more scheduled conversations, which were more productive in achieving bidirectional communication. A targeted simulation curriculum addressing these areas may improve patient, decision maker, and provider satisfaction, while promoting patient-centered care.
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Affiliation(s)
| | - Nicole F Siparsky
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
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18
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Mazzu MA, Campbell ML, Schwartzstein RM, White DB, Mitchell SL, Fehnel CR. Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review. J Pain Symptom Manage 2023; 66:e399-e426. [PMID: 37244527 PMCID: PMC10527530 DOI: 10.1016/j.jpainsymman.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU. SETTING AND DESIGN Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. PARTICIPANTS Adults (age 18 and over) undergoing WMV in the ICU. MEASUREMENTS Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients. CONCLUSION High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.
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Affiliation(s)
- Maria A Mazzu
- University of New England College of Osteopathic Medicine (M.A.M.), Biddeford, Maine, USA
| | | | - Richard M Schwartzstein
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA
| | - Douglas B White
- University of Pittsburgh School of Medicine (D.B.W.), Pittsburgh, Pennsylvania, USA
| | - Susan L Mitchell
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Hebrew SeniorLife, Marcus Institute for Aging Research (S.L.M., C.R.F.), Boston, Massachusetts, USA
| | - Corey R Fehnel
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Hebrew SeniorLife, Marcus Institute for Aging Research (S.L.M., C.R.F.), Boston, Massachusetts, USA.
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19
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Lei Y, Zhou Q, Tao Y. Decision Aids in the ICU: a scoping review. BMJ Open 2023; 13:e075239. [PMID: 37607783 PMCID: PMC10445349 DOI: 10.1136/bmjopen-2023-075239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
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.
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Affiliation(s)
- Yuling Lei
- Department of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Qi Zhou
- Department of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Yuexian Tao
- Department of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
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20
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Mesfin N, Wormwood J, Wiener RS, Still M, Xu CS, Palmer J, Linsky AM. Impact of the COVID-19 Pandemic on Providing Recommendations During Goals-of-Care Conversations: A Multisite Survey. J Palliat Med 2023; 26:951-959. [PMID: 36944150 PMCID: PMC10398728 DOI: 10.1089/jpm.2022.0394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 03/23/2023] Open
Abstract
Background: Goals-of-care conversations (GoCCs) are essential for individualized end-of-life care. Shared decision-making (SDM) that elicits patients' goals and values to collaboratively make life sustaining treatment (LST) decisions is best practice. However, it is unknown how the COVID-19 pandemic onset and associated changes to care delivery, stress on providers, and clinical uncertainty affected SDM and recommendation-making during GoCCs. Aim: To assess providers' attitudes and behaviors related to GoCCs during the COVID-19 pandemic and identify factors associated with provision of LST recommendations. Design: Survey of United States Veterans Health Administration (VA) health care providers. Setting/Participants: Health care providers from 20 VA facilities with high COVID-19 caseloads early in the pandemic who had authority to place LST orders and practiced in select specialties (n = 3398). Results: We had 323 respondents (9.5% adjusted response rate). Most were age ≥50 years (51%), female (63%), non-Hispanic white (64%), and had ≥1 GoCC per week during peak-COVID-19 (78%). Compared with pre-COVID-19, providers believed it was less appropriate and felt less comfortable giving an LST recommendation during peak-COVID-19 (p < 0.001). One-third (32%) reported either "never" or "rarely" giving an LST recommendation during GoCCs at peak-COVID-19. In adjusted regression models, being a physician and discussing patients' goals and values were positively associated with giving an LST recommendation (B = 0.380, p = 0.031 and B = 0.400, p < 0.001, respectively) at peak-COVID-19. Conclusion: Providers who discuss patients' preferences and values are more likely to report giving a recommendation; both behaviors are markers of SDM during GoCCs. Our findings suggest potential areas for training in conducting patient-centered GoCCs.
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Affiliation(s)
- Nathan Mesfin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jolie Wormwood
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- University of New Hampshire, Durham, New Hampshire, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michael Still
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Chris S. Xu
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Jennifer Palmer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Amy M. Linsky
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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21
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Goss AL, Voumard RR, Engelberg RA, Curtis JR, Creutzfeldt CJ. Do They Have a Choice? Surrogate Decision-Making After Severe Acute Brain Injury. Crit Care Med 2023; 51:924-935. [PMID: 36975213 PMCID: PMC10271970 DOI: 10.1097/ccm.0000000000005850] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
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.
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Affiliation(s)
- Adeline L Goss
- Division of Neurology, Department of Internal Medicine, Highland Hospital, Oakland, CA
| | - Rachel Rutz Voumard
- Department of Medicine, Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Clinical Ethics Unit, Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA
- Cambia Palliative Care Center of Excellence at University of Washington, Harborview Medical Center, Seattle, WA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA
- Cambia Palliative Care Center of Excellence at University of Washington, Harborview Medical Center, Seattle, WA
| | - Claire J Creutzfeldt
- Cambia Palliative Care Center of Excellence at University of Washington, Harborview Medical Center, Seattle, WA
- Department of Neurology, University of Washington, Harborview Medical Center, Seattle, WA
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22
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White DB, Andersen SK. Conversations on Goals of Care With Hospitalized, Seriously Ill Patients. JAMA 2023; 329:2021-2022. [PMID: 37210664 DOI: 10.1001/jama.2023.8970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- Douglas B White
- Program on Ethics and Decision Making in Critical Illness, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah K Andersen
- Program on Ethics and Decision Making in Critical Illness, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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23
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Gagne-Henderson R, Holland C, Walshe C. Sense of Coherence at End of Life in Older People: An Interpretive Description. J Hosp Palliat Nurs 2023; 25:165-172. [PMID: 37081670 DOI: 10.1097/njh.0000000000000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
As people age, losses accumulate (ie, the death of family and friends, the loss of agility, and the loss of independence). Such losses have an impact on one's Sense of Coherence, that is, one's ability to see the world as comprehensible, manageable, and meaningful. Antonovsky deemed Sense of Coherence as a mostly stable state by the age of 30 years. Until now, there has not been an investigation into how serial loss of resources affects older people as they near the end of life. Sense of Coherence was used as the theoretical framework for this study to answer the question of how older people maintain or regain a Sense of Coherence in the presence of serious illness as they near death. Data were gathered using semistructured interviews and guided by interpretive description. This investigation found new concepts that contribute to Antonovsky's midlevel theory of salutogenesis and the construct of Sense of Coherence. Those are Incomprehensibility and Serial Loss of General Resistance Resources. The results indicate that the crux of a strong Sense of Coherence for this population is excellent communication and a coherent "big-picture" conversation.
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24
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Stahl D. Misuses of "Quality of Life" Judgments in End-of-Life Care. Chest 2023; 163:1228-1231. [PMID: 37164577 DOI: 10.1016/j.chest.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/02/2022] [Accepted: 11/23/2022] [Indexed: 05/12/2023] Open
Affiliation(s)
- Devan Stahl
- Department of Religion, Baylor University, Waco, TX.
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25
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You H, Ma JE, Haverfield MC, Oyesanya TO, Docherty SL, Johnson KS, Cox CE, Ashana DC. Racial Differences in Physicians' Shared Decision-Making Behaviors during Intensive Care Unit Family Meetings. Ann Am Thorac Soc 2023; 20:759-762. [PMID: 36790912 PMCID: PMC10174123 DOI: 10.1513/annalsats.202212-997rl] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Affiliation(s)
| | - Jessica E. Ma
- Durham Veterans Affairs Health SystemDurham, North Carolina
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26
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Lincoln TE, Buddadhumaruk P, Arnold RM, Scheunemann LP, Ernecoff NC, Chang CCH, Carson SS, Hough CL, Curtis JR, Anderson W, Steingrub J, Peterson MW, Lo B, Matthay MA, White DB. Association Between Shared Decision-Making During Family Meetings and Surrogates' Trust in Their ICU Physician. Chest 2023; 163:1214-1224. [PMID: 36336000 PMCID: PMC10258434 DOI: 10.1016/j.chest.2022.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Although trust is central to successful physician-family relationships in ICUs, little is known about how to promote surrogates' trust of ICU physicians in this setting. RESEARCH QUESTION Does the conduct of family conferences and physicians' use of shared decision-making (SDM) within family conferences impact surrogates' trust in the physician? STUDY DESIGN AND METHODS A mixed-methods secondary analysis was done of a multicenter prospective cohort study of 369 surrogate decision-makers of 204 decisionally incapacitated patients at high risk of death or severe functional impairment within 13 ICUs at six US medical centers between 2008 and 2012. Surrogates completed the Abbreviated Wake Forest Physician Trust Scale (range, 5-25) before and after an audio-recorded family conference conducted within 5 days of ICU admission. We qualitatively coded transcribed conferences to determine physicians' use of five SDM behaviors: discussing surrogate's role, explaining medical condition and prognosis, providing emotional support, assessing understanding, and eliciting patient's values and preferences. Using multivariable linear regression with adjustment for clustering, we assessed whether surrogates' trust in the physician increased after the family meeting; we also examined whether the number of SDM behaviors used by physicians during the family meeting impacted trust scores. RESULTS In adjusted models, conduct of a family meeting was associated with increased trust (average change, pre- to post family meeting: 0.91 point [95% CI, 0.4-1.4; P < .01]). Every additional element of SDM used during the family meeting, including discussing surrogate's role, providing emotional support, assessing understanding, and eliciting patient's values and preferences, was associated with a 0.37-point increase in trust (95% CI, 0.08-0.67; P = .01). If all four elements were used, trust increased by 1.48 points. Explaining medical condition or prognosis was observed in nearly every conference (98.5%) and was excluded from the final model. INTERPRETATION The conduct of family meetings and physicians' use of SDM behaviors during meetings were both associated with increases in surrogates' trust in the treating physician.
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Affiliation(s)
- Taylor E Lincoln
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA.
| | - Praewpannarai Buddadhumaruk
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | - Leslie P Scheunemann
- Division of Geriatrics and Gerontology, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Chung-Chou H Chang
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Shannon S Carson
- Division of Pulmonary Disease and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Wendy Anderson
- Department of Medicine and Division of Hospital Medicine and Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Jay Steingrub
- Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, MA and Tufts University School of Medicine, Boston, MA
| | - Michael W Peterson
- Department of Medicine, University of California San Francisco Fresno Medical Education Program, Fresno, CA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco Fresno Medical Education Program, Fresno, CA
| | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, University of Massachusetts Chan Medical School, Baystate, MA
| | - Douglas B White
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Spiritual Care in the Intensive Care Unit: Experiences of Dutch Intensive Care Unit Patients and Relatives. Dimens Crit Care Nurs 2023; 42:83-94. [PMID: 36720033 DOI: 10.1097/dcc.0000000000000570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND/OBJECTIVE To gain insight into both patients' and relatives' experiences with spiritual care (SC) in the intensive care unit (ICU). METHODS Method used was qualitative interviewing. This was a thematic, topic-centered, biographical, and narrative approach, using semistructured interviews with thematic analysis. A purposive sampling method was used to select a sample of ICU patients and ICU patients' relatives. An interview guide facilitated individual, semistructured interviews. The interview data were recorded by means of note-taking and audio-recording. Verbatim transcripts were compiled for analysis and interpretation. RESULTS All 12 participants-7 ICU patients and 5 family members of 5 other ICU patients-experienced ICU admission as an existential crisis. Participants would appreciate the signaling of their spiritual needs by ICU health care professionals (HCPs) at an early stage of ICU admission and subsequent SC provision by a spiritual caregiver. They regarded the spiritual caregiver as the preferred professional to address spiritual needs, navigate during their search for meaning and understanding, and provide SC training in signaling spiritual needs to ICU HCPs. DISCUSSION Early detection of existential crisis signals with ICU patients and relatives contributes to the mapping of spiritual and religious needs. Spiritual care training of ICU HCPs in signaling spiritual needs by ICU patients and relatives is recommended. Effective SC contributes to creating room for processing emotions, spiritual well-being, and satisfaction with integrated SC as part of daily ICU care.
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28
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Milnes SL, Kerr DC, Hutchinson A, Simpson NB, Mantzaridis Y, Corke C, Bailey M, Orford NR. Effect of communication skills training on documentation of shared decision-making for patients with life-limiting illness: An observational study in an intensive care unit. CRIT CARE RESUSC 2023; 25:20-26. [PMID: 37876985 PMCID: PMC10581275 DOI: 10.1016/j.ccrj.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objectives This article aims to examine the association between a shared decision-making (SDM) clinical communication training program and documentation of SDM for patients with life-limiting illness (LLI) admitted to intensive care. Methods This article used a prospective, longitudinal observational study in a tertiary intensive care unit (ICU). Outcomes included the proportion of patients with SDM documented on an institutional Goals of Care Form during hospital admission, as well as characteristics, outcomes, and factors associated with an SDM admission. Intervention Clinical communication skills training (iValidate) and clinical support program are the intervention for this study. Results A total of 325 patients with LLI were admitted to the ICU and included in the study. Overall, 184 (57%) had an SDM admission, with 79% of Goals of Care Form completed by an iValidate-trained doctor. Exposure to an iValidate-trained doctor was the strongest predictor of an ICU patient with LLI having an SDM admission (odds ratio: 22.72, 95% confidence interval: 11.91-43.54, p < 0.0001). A higher proportion of patients with an SDM admission selected high-dependency unit-level care (29% vs. 12%, p < 0.001) and ward-based care (36% vs. 5%, p < 0.0001), with no difference in the proportion of patients choosing intensive care or palliative care. The proportion of patients with no deterioration plan was higher in the non-SDM admission cohort (59% vs. 0%, p < 0.0001). Conclusions Clinical communication training that explicitly teaches identification of patient values is associated with improved documentation of SDM for critically ill patients with LLI. Understanding the relationship between improved SDM and patient, family, and clinical outcomes requires appropriately designed high-quality trials randomised at the patient or cluster level.
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Affiliation(s)
- Sharyn L. Milnes
- University Hospital Geelong, Barwon Health, Geelong, Australia
- Institute for Healthcare Transformation, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Geelong, Australia
- Institute for Innovation in Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Deakin University, Geelong, Australia
| | - Debra C. Kerr
- Institute for Healthcare Transformation, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Geelong, Australia
| | - Ana Hutchinson
- Institute for Healthcare Transformation, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Geelong, Australia
| | - Nicholas B. Simpson
- University Hospital Geelong, Barwon Health, Geelong, Australia
- Institute for Innovation in Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Deakin University, Geelong, Australia
| | | | - Charlie Corke
- University Hospital Geelong, Barwon Health, Geelong, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
| | - Neil R. Orford
- University Hospital Geelong, Barwon Health, Geelong, Australia
- Institute for Innovation in Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Deakin University, Geelong, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Australia
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29
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The Perspectives of Surrogates and Healthcare Providers Regarding SDM (Shared Decision-Making). DISEASE MARKERS 2023; 2023:6251492. [PMID: 36820102 PMCID: PMC9938785 DOI: 10.1155/2023/6251492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/02/2022] [Accepted: 01/27/2023] [Indexed: 02/13/2023]
Abstract
The purpose of this paper is to explore the attitudes of surrogacy and medical service providers toward SDM and to identify the barriers and promoters of SDM in this population. To this end, we conducted a qualitative study of surrogacy and medical service providers in the First Affiliated Hospital of Soochow University using semistructured interviews. Thirty participants (11 agents, 12 ICU physicians, and 7 ICU nurses) were interviewed. The three stakeholders showed different attitudes toward SDM. They reported barriers to SDM, including insufficient cognition of decision-makers, high expectations, negative psychological experiences, previous decision-making experiences, excessive workload, heavy financial burden, and lack of decision AIDS. They reported facilitators of SDM, including trust, effective communication, decision support, value clarification, outcome commitment, and continuous service. This study explored the different attitudes of the three stakeholders and identified various barriers and facilitators of SDM. It highlights the need to develop localised decision AIDS and to involve agents and nurses more in the decision-making process. Therefore, this paper identifies barriers and facilitators of SDM in this population. In addition, the study identified various barriers and facilitators to SDM and highlighted the need to develop localised decision AIDS and involve agents and nurses more in the decision-making process. Finally, the barriers and facilitators of SDM are established. The paper also shows that the development of localized decision AIDS and greater involvement of agents and nurses in the decision-making process are integral to good treatment outcomes.
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Harmon A, Jordan M, Platt A, Wilson J, Keith K, Chandrashekaran S, Schlichte L, Pendergast J, Ming D. Goal-Concordance in Children with Complex Chronic Conditions. J Pediatr 2023; 253:278-285.e4. [PMID: 36257348 DOI: 10.1016/j.jpeds.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 10/01/2022] [Accepted: 10/05/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To characterize delivery of goal-concordant end-of-life (EOL) care among children with complex chronic conditions and to determine factors associated with goal-concordance. STUDY DESIGN This was a retrospective review of goals of care discussions for 272 children with at least 1 complex chronic condition who died at a tertiary care hospital between January 1, 2014, and December 31, 2017. Goals of care and code status were assessed before and within the last 72 hours of life. Goals of care discussions were coded as full interventions; considering withdrawal of interventions (palliation); planned transition to palliation; or actively transitioning/transitioned to palliation. RESULTS In total, 158 children had documented goals of care discussions before and within the last 72 hours of life, 18 had goals of care discussions only >72 hours before death, 54 only in the last 72 hours of life, and 42 had no documented goals of care. For children with goals of care, EOL care was goal-concordant for 82.2%, discordant in 7%, and unclear in 10.8%. Black children had a greater than 8-fold greater odds of discordant care compared with White children (OR 8.34, P = .007). Comparison of goals of care and code status before and within the last 72 hours of life revealed trends toward nonescalation of care. Specifically, rates of active palliation increased from 11.7% to 63.0%, and code status shifted from 32.6% do not resuscitate to 65.2% (P < .001). CONCLUSIONS In this cohort, a majority of children had documented goals of care discussions and received goal-concordant EOL care. However, Black children had greater odds of receiving goal-discordant care. Goals of care and code status shifted toward palliation during the last 72 hours of life.
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Affiliation(s)
- Alexis Harmon
- Department of Pediatrics, McGaw Medical Center of Northwestern University, Chicago, IL
| | - Megan Jordan
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Alyssa Platt
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Jonathon Wilson
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Kevin Keith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | | | - Jane Pendergast
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - David Ming
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.
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31
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Brunker LB, Boncyk CS, Rengel KF, Hughes CG. Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges. Clin Interv Aging 2023; 18:93-112. [PMID: 36714685 PMCID: PMC9879046 DOI: 10.2147/cia.s365968] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/12/2023] [Indexed: 01/23/2023] Open
Abstract
There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.
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Affiliation(s)
- Lucille B Brunker
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly F Rengel
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Giabicani M, Arditty L, Mamzer MF, Fournel I, Ecarnot F, Meunier-Beillard N, Bruneel F, Weiss E, Spranzi M, Rigaud JP, Quenot JP. Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs. PLoS One 2023; 18:e0284756. [PMID: 37098023 PMCID: PMC10128920 DOI: 10.1371/journal.pone.0284756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/08/2023] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs. METHODS Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians. RESULTS Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts. CONCLUSION Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.
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Affiliation(s)
- Mikhael Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
| | - Laure Arditty
- Service de Réanimation, Centre Hospitalier Intercommunal des Alpes du Sud, Gap, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
- Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Isabelle Fournel
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, Besançon, France
- EA3920, Université de Bourgogne-Franche Comté, Besançon, France
| | - Nicolas Meunier-Beillard
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, Dijon, France
| | - Fabrice Bruneel
- Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
| | - Marta Spranzi
- Center for Clinical Ethics, AP-HP, Paris and Université de Versailles Saint-Quentin en Yvelines, Versailles, France
| | - Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, CH de Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, CHU de Caen, Caen, France
| | - Jean-Pierre Quenot
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
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Hernandez SF, Agarwal S. Decoding code status after cardiac arrest. Resuscitation 2022; 181:37-39. [PMID: 36272617 DOI: 10.1016/j.resuscitation.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sachin Agarwal
- Department of Neurology, Division of Critical Care & Hospitalist Neurology, Columbia University Irving Medical Center & New York Presbyterian Hospital, New York, United States.
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Murali KP, Hua M. What End-of-Life Communication in ICUs Around the World Teaches Us About Shared Decision-Making? Chest 2022; 162:949-950. [DOI: 10.1016/j.chest.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022] Open
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Murali KP, Fonseca LD, Blinderman CD, White DB, Hua M. Clinicians' Views on the use of triggers for specialist palliative care in the ICU: A qualitative secondary analysis. J Crit Care 2022; 71:154054. [DOI: 10.1016/j.jcrc.2022.154054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
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Jöbges S, Denke C, Seidlein AH. Optimierung der Zugehörigenbetreuung – angehörigenzentrierte Intensivmedizin. Med Klin Intensivmed Notfmed 2022; 117:575-583. [DOI: 10.1007/s00063-022-00964-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/29/2022] [Accepted: 08/18/2022] [Indexed: 12/01/2022]
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Integrating Narrative Goals of Care in the Medical Intensive Care Unit: Impact on Educational and Clinical Outcomes. ATS Sch 2022; 3:449-459. [PMID: 36312808 PMCID: PMC9585691 DOI: 10.34197/ats-scholar.2022-0003in] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background High-quality goals of care (GOC) communication is fundamental to providing excellent critical care. Objective Educate medical intensive care unit (MICU) clinicians, design and implement workflows relating to GOC communication, and measure the impact on communication proficiency and rate of GOC documentation. Methods Guided by Lean Six Sigma principles, an interprofessional team from palliative and critical care tailored a multicomponent intervention—the 3-Act Model communication training and workflow modification—to equip and empower the pulmonary and critical care medicine (PCCM) fellow as the clinical lead for GOC discussions. Fellows’ education included in-person narrative reflection, asynchronous online didactic and demonstration videos of the 3-Act Model, online roleplays, and direct observation leading GOC discussions in the ICU. PCCM fellows were objectively evaluated for proficiency using the Goals of Care Assessment Tool. To evaluate the impact of our intervention on documented GOC conversations, we performed a retrospective chart review over two 3-month periods (before and after intervention) when the MICU cared exclusively for critically ill patients with coronavirus disease (COVID-19). Results All PCCM fellows demonstrated proficiency in GOC communication via online simulated roleplays, as well as in observed bedside GOC communication. Per chart review of patients with a minimum of 7 consecutive days in the MICU, documented GOC conversations were found for 5.55% (2/36) of patients during the preintervention period and for 28.89% (13/45) of patients in the postintervention period. Palliative care consults increased in the pre- versus postintervention period: for all patients, 4.85% versus 14.52% (P < 0.05); for patients age ⩾80 years, 3.54% versus 29.41% (P < 0.05); and for patients with MICU length of stay ⩾7 days, 2.78% versus 24.44% (P < 0.05). Conclusion Combining 3-Act Model education for PCCM fellows with Lean Six Sigma quality improvement resulted in effective GOC communication training and improved palliative care integration in the ICU.
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Bishop C, Jackson L, Brown A. Primary palliative care skills in caring for surgical patients in the neonatal intensive care unit. Semin Pediatr Surg 2022; 31:151201. [PMID: 36038212 DOI: 10.1016/j.sempedsurg.2022.151201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Van Scoy LJ, Scott AM, Green MJ, Witt PD, Wasserman E, Chinchilli VM, Levi BH. Communication Quality Analysis: A user-friendly observational measure of patient-clinician communication. COMMUNICATION METHODS AND MEASURES 2022; 16:215-235. [PMID: 37063460 PMCID: PMC10104441 DOI: 10.1080/19312458.2022.2099819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Communication Quality Analysis (CQA) is a rigorous transcript-based coding method for assessing clinical communication quality. We compared the resource-intensive transcript-based version with a streamlined real-time version of the method with respect to feasibility, validity, reliability, and association with traditional measures of communication quality. Simulated conversations between 108 trainees and 12 standardized patients were assessed by 7 coders using the two versions of CQA (transcript and real-time). Participants also completed two traditional communication quality assessment measures. Real-time CQA was feasible and yielded fair to excellent reliability, with some caveats that can be addressed in future work. CQA ratings were moderately correlated with traditional measures of communication quality, suggesting that CQA captures different aspects of communication quality than do traditional measures. Finally, CQA did not exhibit the ceiling effects observed in the traditional measures of communication quality. We conclude that real-time CQA is a user-friendly method for assessing communication quality that has the potential for broad application in training, research, and intervention contexts and may offer improvements to traditional, self-rated communication measures.
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Affiliation(s)
- Lauren Jodi Van Scoy
- Departments of Medicine, Penn State College of Medicine, Hershey, USA
- Department of Humanities, Penn State College of Medicine, Hershey, USA
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - Allison M Scott
- Department of Communication; University of Kentucky, Lexington, USA
| | - Michael J. Green
- Departments of Medicine, Penn State College of Medicine, Hershey, USA
- Department of Humanities, Penn State College of Medicine, Hershey, USA
| | - Pamela D. Witt
- Departments of Medicine, Penn State College of Medicine, Hershey, USA
| | - Emily Wasserman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Hershey, USA
- Department of Pediatrics Penn State College of Medicine, Hershey, USA
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Choi A, Sanft T. Establishing Goals of Care. Med Clin North Am 2022; 106:653-662. [PMID: 35725231 DOI: 10.1016/j.mcna.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Establishing goals of care (GOC) is a crucial component of a patient's treatment plan. The need for better physician-patient communication in this area has been recognized for decades, yet several gaps remain. Challenges exist for both physician and patient. Physicians should pursue a patient-led approach, exercise cultural competency, and use various communication techniques to guide patients when establishing GOC.
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Affiliation(s)
- Alex Choi
- Yale Palliative Care Program, Yale New Haven Hospital, New Haven, CT, USA.
| | - Tara Sanft
- Survivorship Clinic, Yale New Haven Hospital, New Haven, CT, USA
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Global Comparison of Communication of End-of-Life Decisions in the ICU. Chest 2022; 162:1074-1085. [DOI: 10.1016/j.chest.2022.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 03/22/2022] [Accepted: 05/04/2022] [Indexed: 11/20/2022] Open
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Mentzelopoulos SD, Chen S, Nates JL, Kruser JM, Hartog C, Michalsen A, Efstathiou N, Joynt GM, Lobo S, Avidan A, Sprung CL. Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill. Crit Care 2022; 26:106. [PMID: 35418103 PMCID: PMC9009016 DOI: 10.1186/s13054-022-03971-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions.
Methods The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset. Results In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008]. Conclusions Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03971-9.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675, Athens, Greece.
| | - Su Chen
- D2, K Lab, Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care Medicine, The University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Christiane Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité University Medicine Berlin, Berlin, Germany.,Klinik Bavaria, Kreischa, Germany
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine, and Pain Therapy, Konstanz Hospital, Konstanz, Germany
| | - Nikolaos Efstathiou
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Suzana Lobo
- Critical Care Division - Faculty of Medicine São José do Rio Preto, São Paulo, Brazil
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Kaldjian LC. To Inform, Recommend, and Sometimes Persuade: The Ethics of Physician Influence in Shared Decision Making. South Med J 2022; 115:244-246. [PMID: 35365837 DOI: 10.14423/smj.0000000000001373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Lauris C Kaldjian
- From the Department of Internal Medicine and Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City
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Myers J, Kim GL, Bytautas J, Webster F. Differing Conceptualizations of the Goals of Care Discussion: A Critical Discourse Analysis. J Pain Symptom Manage 2022; 63:495-502. [PMID: 34954070 DOI: 10.1016/j.jpainsymman.2021.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/03/2021] [Accepted: 12/11/2021] [Indexed: 11/24/2022]
Abstract
CONTEXT The goals of care discussion (GOCD) has been positioned as an improvement strategy to address discordance between care decisions made by seriously ill patients and care received. Interventions aimed at improving GOCDs however have had limited success. This may in part be due to the considerable variation in views on the essential components and expected outcomes of a GOCD. This variability, and consequently clinical approaches to GOCDs, may reflect fundamental differences in how the GOCD is conceptualized. OBJECTIVE To identify and characterize differing conceptualizations of the GOCD. METHODS Critical discourse analysis was used to qualitatively examine GOCDs documented for inpatients of 35 Canadian palliative medicine (PM), critical care medicine (CCM) and general internal medicine (GIM) physicians. Patterns in the ways the GOCD had been constructed were characterized by identifying different aspects of the approaches used by clinicians. RESULTS GOCD notes varied in the predominant style and tone (from narrative to biomedical), predominant information source (patient/family to physician), and contribution of the patient's perspective. Notably binary differences were also found in the locus of goals and located either with the patient or with the broad concept of treatments. Although not exclusively, locus of goals tended to be with the patient among PM physicians and with treatments among CCM and GIM physicians. CONCLUSION These findings offer clinical evidence for differing conceptualizations of the GOCD and orientations to goals as either person-centered or treatment-centered. This phenomenon may be in part discipline-based and has important implications for both clinical practice and training experiences.
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Affiliation(s)
- Jeff Myers
- Division of Palliative Care, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
| | - Ginah L Kim
- Division of Palliative Care, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jessica Bytautas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Fiona Webster
- Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, Canada
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Gerrity C, Farley S, Barks MC, Ubel PA, Brandon D, Pollak KI, Lemmon ME. Decision Making for Infants With Neurologic Conditions. J Child Neurol 2022; 37:202-209. [PMID: 35133902 PMCID: PMC9038601 DOI: 10.1177/08830738211056779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Peter A. Ubel
- Duke University School of Medicine,Fuqua School of Business and Sanford School of Public Policy, Duke University
| | - Debra Brandon
- Duke University School of Nursing,Department of Pediatrics, Duke University School of Medicine
| | - Kathryn I. Pollak
- Department of Population Health Sciences, Duke University School of Medicine,Duke Cancer Institute, Duke University School of Medicine
| | - Monica E. Lemmon
- Department of Pediatrics, Duke University School of Medicine,Department of Population Health Sciences, Duke University School of Medicine
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Baumann A, Thilly N, Joseph L, Claudot F. Ethical reflection support for potential organ donors' relatives: A narrative review. Nurs Ethics 2022; 29:660-674. [PMID: 35172649 DOI: 10.1177/09697330211015274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Even in countries with an opt-out or presumed consent system, relatives have a considerable influence on the post-mortem organ harvesting decision. However, their reflection capacity may be compromised by grief, and they are, therefore, often prone to choose refusal as default option. Quite often, it results in late remorse and dissatisfaction. So, a high-quality reflection support seems critical to enable them to gain a stable position and a long-term peace of mind, and also avoid undue loss of potential grafts. In practice, recent studies have shown that the ethical aspects of reflection are rarely and often poorly discussed with relatives and that no or incomplete guidance is offered. No review of the literature is available to date, although it could be of value to improve the quality of the daily practice. OBJECTIVES The objective was to review and synthesize the main concepts and approaches, theories and practices of ethical reflection support of the relatives or surrogates of potential post-mortem organ donors. RESEARCH DESIGN A narrative review was performed in the medical, psychological and ethical fields using PubMed, PsycArticles and Web of Science databases (1980-2020). RESULTS Out of 150 papers, 25 were finally retained. Four themes were drawn: the moral status of the potential post-mortem organ donor, the principlistic approach with its limits and critics, the narrative approach and the transcendental approach. DISCUSSION This review suggests an extension of psychological support towards ethical reflection support. The process of helping relatives in their ethical exploration of post-mortem organ donation is psychologically and morally characterized. The need for specialized professionals educated and experienced both in clinical psychology and in health ethics to carry out this task is discussed. PRACTICAL IMPACT This review could contribute to optimize the quality of the ethical reflection support by initiating an evolution from an empirical, partial and individual-dependent support to a more systematized, professionalized and exhaustive support.
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Affiliation(s)
- Antoine Baumann
- Assistance Publique - Hôpitaux de Paris, France; Université de Lorraine, France
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Association between prognostic awareness and quality of life in patients with advanced cancer. Qual Life Res 2022; 31:2367-2374. [PMID: 35119564 DOI: 10.1007/s11136-022-03097-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Despite the current guidelines supporting open communication about serious news, the evidence about the impact of prognostic awareness on the quality of life in cancer patients is not clear. The aim of this study was to assess the association between quality of life and prognostic awareness in patients with advanced cancer. METHODS This was a cross-sectional study which involved patients (n = 129) with incurable advanced cancer (estimated by oncologist using 12-month surprise question). Data were collected at oncology departments at 3 hospitals using structured interview in which patients were asked about their quality of life (using Integrated Palliative Outcome Scale-IPOS and a single-item global measure), prognostic awareness, information needs and demographics. RESULTS Only 16% of the sample was completely aware of prognosis and 57% was partially aware. Accurate prognostic awareness was significantly associated (p = 0.02) with lower level of quality of life between (when measured by both the IPOS and the single-item scale) patients with accurate prognostic awareness (M = 37.1; 10.4) and partially aware (M = 31.9; 9.1) and unaware patients (M = 30; 7.4). Detailed analysis showed that significant difference between groups was found only for physical symptoms subscales (p = 0.002), not for emotional and communication subscales. CONCLUSION Prognostic awareness was found to be negatively associated with physical domain of quality of life, but not with emotional and communication domains. More research is needed on personality factors that might influence the development of prognostic awareness and quality of life.
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Hart AS, Matthews AK, Arslanian-Engoren C, Patil CL, Krassa TJ, Bonner GJ. Experience of African American Surrogate Decision Makers of Patients With Dementia. J Hosp Palliat Nurs 2022; 24:84-94. [PMID: 34840282 DOI: 10.1097/njh.0000000000000822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Dementia cases are expected to grow for African Americans and surrogate decision makers (SDMs) will have a significant role at the end of life (EOL). This qualitative exploratory case study used Cognitive Task Analysis and an integrated conceptual framework to understand the EOL decision experience of African American SDMs for patients with advanced dementia. Using a holistic multiple-case design, 8 African American SDMs were interviewed about their experiences with the decision-making process, including role acceptance, role enactment, and emotional outcomes of decision making. Thirteen themes germane to understanding the EOL decision experience of African American SDMs were identified. Findings suggest African American SDMs often lack sufficient knowledge of disease prognosis and intervention options to make informed treatment choices at EOL. In particular, African Americans extend the caregiver role to SDM for patients with dementia at EOL without being fully aware of the role and decision-making responsibilities. Surrogates lacked a general understanding of EOL options resulting in underutilization of hospice and palliative care and subsequent regret, and few interventions exist to improve the uptake of EOL care services. There is a need to develop culturally appropriate role preparation, education, and decision support to improve EOL treatment decisions and emotional adjustment of surrogates of patients with advanced dementia, which should be rendered early and throughout the illness trajectory.
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Ge C, Goss AL, Crawford S, Goostrey K, Buddadhumaruk P, Shields AM, Hough CL, Lo B, Carson SS, Steingrub J, White DB, Muehlschlegel S. Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study. Crit Care Explor 2022; 4:e0640. [PMID: 35224505 PMCID: PMC8863127 DOI: 10.1097/cce.0000000000000640] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Withdrawal-of-life-sustaining treatments (WOLST) rates vary widely among critically ill neurologic patients (CINPs) and cannot be solely attributed to patient and family characteristics. Research in general critical care has shown that clinicians prognosticate to families with high variability. Little is known about how clinicians disclose prognosis to families of CINPs, and whether any associations exist with WOLST. OBJECTIVES Primary: to demonstrate feasibility of audio-recording clinician-family meetings for CINPs at multiple centers and characterize how clinicians communicate prognosis during these meetings. Secondary: to explore associations of 1) clinician, family, or patient characteristics with clinicians' prognostication approaches and 2) prognostication approach and WOLST. DESIGN SETTING AND PARTICIPANTS Forty-three audio-recorded clinician-family meetings during which prognosis was discussed from seven U.S. centers for 39 CINPs with 88 family members and 27 clinicians. MAIN OUTCOMES AND MEASURES Two investigators qualitatively coded transcripts using inductive methods (inter-rater reliability > 80%) to characterize how clinicians prognosticate. We then applied univariate and multivariable multinomial and binomial logistic regression. RESULTS Clinicians used four distinct prognostication approaches: Authoritative (21%; recommending treatments without discussing values and preferences); Informational (23%; disclosing just the prognosis without further discussions); advisory (42%; disclosing prognosis followed by discussion of values and preferences); and responsive (14%; eliciting values and preferences, then disclosing prognosis). Before adjustment, prognostication approach was associated with center (p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists; p = 0.001), patient age (p = 0.08), diagnosis (p = 0.059), and meeting length (p = 0.03). After adjustment, only clinician specialty independently predicted prognostication approach (p = 0.027). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). WOLST was more likely in older patients (p = 0.059) and with more experienced clinicians (p = 0.07). Prognostication approach was not independently associated with WOLST (p = 0.198). CONCLUSIONS AND RELEVANCE It is feasible to audio-record sensitive clinician-family meetings about CINPs in multiple ICUs. We found that clinicians prognosticate with high variability. Our data suggest that larger studies are warranted in CINPs to examine the role of clinicians' variable prognostication in WOLST decisions.
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Affiliation(s)
- Connie Ge
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Adeline L Goss
- Department of Internal Medicine, Division of Neurology, Highland Hospital, Oakland, CA
| | - Sybil Crawford
- Department of Graduate School of Nursing, University of Massachusetts Tan Chingfen Graduate School of Nursing, Worcester, MA
| | - Kelsey Goostrey
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | | | - Anne-Marie Shields
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Catherine L Hough
- Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, Oregon Health Sciences University, Portland, OR
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Shannon S Carson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jay Steingrub
- Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
- Department of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, MA
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA
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Auriemma CL, O'Donnell H, Jones J, Barbati Z, Akpek E, Klaiman T, Halpern SD. Patient perspectives on states worse than death: A qualitative study with implications for patient-centered outcomes and values elicitation. Palliat Med 2022; 36:348-357. [PMID: 34965775 PMCID: PMC9813946 DOI: 10.1177/02692163211058596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Seriously ill patients rate several health outcomes as states worse than death. It is unclear what factors underlie such valuations, and whether consideration of such states is useful when making medical decisions. AIM We sought to (1) use qualitative approaches to identify states worse than death, (2) identify attributes common to such undesirable health states, and (3) determine how participants might use information on these states in making medical decisions. DESIGN Qualitative study of semi-structured interviews utilizing content analysis with constant comparison techniques. SETTING, PARTICIPANTS We interviewed adults age 65 or older with serious illnesses after discharge home from one of two urban, academic hospitals. Eligible patients were purposively sampled to achieve balance in gender and race. RESULTS Of 29 participants, 15 (52%) were female, and 15 were white (52%), with a median age of 72 (interquartile range 69, 75). Various physical, cognitive, and social impairments were identified as states worse than death. The most commonly reported attributes underlying states worse than death were perceived burden on loved ones and inability to maintain human connection. Patients believed information on states worse than death must be individualized, and were concerned their opinions could change with time and fluctuations in health status. CONCLUSIONS Common factors underlying undesirable states suggest that for care to be patient-centered it must also be family-centered. Patients' views on using states worse than death in decision making highlight barriers to using avoidance of such states as a quality measure, but also suggest opportunities for eliciting patients' values.
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Affiliation(s)
- Catherine L Auriemma
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA.,Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Helen O'Donnell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Jones
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Zoe Barbati
- Mixed Methods Research Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - Eda Akpek
- Mixed Methods Research Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - Tamar Klaiman
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA.,Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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