A comparison of the opinions of intensive care unit staff and family members of the treatment intensity received by patients admitted to an intensive care unit: A multicentre survey

Medical Professionals' Treatment Decisions for Critical Patients With Ambiguous Treatment Wishes: A Cross-Sectional Study

Background and Aims

Many patients do not want life-prolonging treatments at critical stages of their illnesses, and are able to communicate their wishes to their families or surrogates. However, few among them have clarity on what such life-prolonging treatments mean or entail. This study clarifies differences in the perspectives of medical professionals based on levels of expertise with respect to treatment decisions for intensive care unit (ICU) patients whose wishes for end-of-life care are ambiguous.

Methods

The cross-sectional study included intensivists, surgeons, and ICU nurses working in 171 Japanese hospitals with ICUs. A total of 837 participants were mailed questionnaires which included questions on the current status and approaches to decision-making with end-of-life care for ICU patients. Additionally, a simulated case study was conducted to investigate the decision-making process for treating patients with uncertain survival rates.

Results

Responses were obtained from 489 participants from 151 hospitals. More than half of the intensivists and ICU nurses reported that family members' requests were respected when the patient had ambiguous treatment preferences. Participants considered the patients' survival probability when deciding to perform emergency surgery, with nurses having significantly higher thresholds than intensivists and surgeons (intensivists: 20.8 ± 20.6, surgeons: 26.6 ± 25.2, ICU nurses: 36.4 ± 26.4; p < 0.001).

Conclusions

Family preferences take precedence over patient preferences when deciding on end-of-life treatments for ICU patients. Shared decision-making should be promoted to correctly share patients' end-of-life medical wishes with surrogate decision-makers and medical practitioners.

Ethical issues surrounding appropriate care for older persons in the Intensive Care Unit

Increasing numbers of older patients are being admitted to the Intensive Care Unit (ICU) as the world's population ages. The biological process of ageing, senescence, results in altered ability to maintain normal homeostasis and organ function, including of the cardiovascular, immune, and neuromuscular systems. This contributes towards increased frailty in older patients, associated with functional limitations and increased vulnerability. Although widely defined using chronological age, the concept of "old age" is thus multifactorial, including biological, but also psychological and sociocultural aspects, which should all be taken into account when considering what is appropriate in terms of ICU admission and management. As for all patients, but perhaps particularly in this subgroup, decisions regarding ICU admission and treatment and the withdrawing and withholding of life support must be individualized.

Accuracy of physician and nurse predictions for 28-day prognosis in ICU: a single center prospective study

The proportion of correctly predicted prognoses and factors associated with prediction accuracy are unknown. The objective of this study was to explore the accuracy of physician and nurse predictions of 28-day mortality in the ICU. This was a prospective observational single-center study. All medical staff in the ICU have access to patient data, can communicate with patients or clients, and can independently predict the prognosis of patients within 24 h of patient admission. The only question of the questionnaire survey was: What is the patient's outcome on day 28 (alive or death)? There were 2155 questionnaires completed by 18 physicians and 1916 submitted by 15 nurses. In the 312 patients included, the 28-day mortality rates were predicted by physicians and nurses. The overall proportion of correct prognosis prediction was 90.1% for physicians and 64.4% for nurses (P = 0.000). There was no significant difference in the overall correct proportion and average correct proportion among physicians with different seniority levels. The overall correct proportion and average correct proportion increased among nurses with seniority. Physicians in the ICU can moderately predict 28-day mortality in critically ill patients. Nurses with a seniority of less than 10 years in ICU cannot accurately predict 28-day mortality in critically ill patients. However, the accuracy of nurses' prediction of patients' 28-day prognosis increased with their seniority in the ICU.

Factors Influencing Potentially Futile Treatments at the End of Life in a Multiethnic Asian Cardiology Setting: A Qualitative Study

BACKGROUND

Modern medicine enables clinicians to save lives and prolong time to death, yet some treatments have little chance of conferring meaningful benefits for patients nearing the end-of-life. What clinicians perceive as driving futile treatment in the non-Western healthcare context is poorly understood.

AIM

This study aimed to explore clinicians' perceptions of the factors that influence futile treatment at the end of life within a tertiary hospital cardiac care setting.

DESIGN

We conducted semi-structured interviews with cardiologists, cardiac surgeons, and palliative care doctors from a large national cardiology center in Singapore. Interviews were transcribed verbatim and thematically analyzed.

RESULTS

A total of 32 clinicians were interviewed. We identified factors that contributed to the provision of potentially futile treatment in these theme areas: patient- and family-related, clinician-related, and institutional and societal factors. Family roles and cultural influences were most commonly cited by participants as affecting end-of-life decisions and altering the likelihood of futile treatment. Specialty-specific alignments within cardiology and availability of healthcare resources were also important factors underpinning futile treatment.

CONCLUSION

Family-related factors were a primary driver for futile treatment in a non-Western, multicultural setting. Future interventions should consider a targeted approach accounting for cultural and contextual factors to prevent and reduce futile treatment.

Shared decision-making in the ICU from the perspective of physicians, nurses and patients: a qualitative interview study

OBJECTIVE

To identify views, experiences and needs for shared decision-making (SDM) in the intensive care unit (ICU) according to ICU physicians, ICU nurses and former ICU patients and their close family members.

DESIGN

Qualitative study.

SETTING

Two Dutch tertiary centres.

PARTICIPANTS

19 interviews were held with 29 participants: seven with ICU physicians from two tertiary centres, five with ICU nurses from one tertiary centre and nine with former ICU patients, of whom seven brought one or two of their close family members who had been involved in the ICU stay.

RESULTS

Three themes, encompassing a total of 16 categories, were identified pertaining to struggles of ICU physicians, needs of former ICU patients and their family members and the preferred role of ICU nurses. The main struggles ICU physicians encountered with SDM include uncertainty about long-term health outcomes, time constraints, feeling pressure because of having final responsibility and a fear of losing control. Former patients and family members mainly expressed aspects they missed, such as not feeling included in ICU treatment decisions and a lack of information about long-term outcomes and recovery. ICU nurses reported mainly opportunities to strengthen their role in incorporating non-medical information in the ICU decision-making process and as liaison between physicians and patients and family.

CONCLUSIONS

Interviewed stakeholders reported struggles, needs and an elucidation of their current and preferred role in the SDM process in the ICU. This study signals an essential need for more long-term outcome information, a more informal inclusion of patients and their family members in decision-making processes and a more substantial role for ICU nurses to integrate patients' values and needs in the decision-making process.

Impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit: A scoping review

BACKGROUND

The use of social media in healthcare continues to evolve. The purpose of this scoping review was to summarize existing research on the impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit (ICU).

METHODS

This review followed established scoping review methods, including an extensive a priori-defined search strategy implemented in the MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials databases to July 10, 2020. Primary research studies reporting on the use of social media by informal caregivers for critically ill patients were included.

RESULTS

We identified 400 unique citations and thirty-one studies met the inclusion criteria. Nine were interventional trials-four randomized controlled trials (RCTs)-and a majority (n = 14) were conducted (i.e., data collected) between 2013 to 2015. Communication platforms (e.g., Text Messaging, Web Camera) were the most commonly used social media tool (n = 17), followed by social networking sites (e.g., Facebook, Instagram) (n = 6), and content communities (e.g., YouTube, SlideShare) (n = 5). Nine studies' primary objective was caregiver satisfaction, followed by self-care (n = 6), and health literacy (n = 5). Nearly every study reported an outcome on usage feasibility (e.g., user attitudes, preferences, demographics) (n = 30), and twenty-three studies reported an outcome related to patient and caregiver satisfaction. Among the studies that assessed statistical significance (n = 18), 12 reported statistically significant positive effects of social media use. Overall, 16 of the 31 studies reported positive conclusions (e.g., increased knowledge, satisfaction, involvement) regarding the use of social media among informal caregivers for critically ill patients.

CONCLUSIONS

Social media has potential benefits for caregivers of the critically ill. More robust and clinically relevant studies are required to identify effective social media strategies used among caregivers for the critically ill.