Impossible decision? An investigation of risk trade-offs in the intensive care unit

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

BACKGROUND

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

AIM

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Strategies for adapting under pressure: an interview study in intensive care units

BACKGROUND

Healthcare systems are operating under substantial pressures. Clinicians and managers are constantly having to make adaptations, which are typically improvised, highly variable and not coordinated across teams. This study aimed to identify and describe the types of everyday pressures in intensive care and the adaptive strategies staff use to respond, with the longer-term aim of developing practical and coordinated strategies for managing under pressure.

METHODS

We conducted qualitative semi-structured interviews with 20 senior multidisciplinary healthcare professionals from intensive care units (ICUs) in 4 major hospitals in the UK. The interviews explored the everyday pressures faced by intensive care staff and the strategies they use to adapt. A thematic template analysis approach was used to analyse the data based on our previously empirically developed taxonomy of pressures and strategies.

RESULTS

The principal source of pressure described was a shortage of staff with the necessary skills and experience to care for the increased numbers and complexity of patients which, in turn, increased staff workload and reduced patient flow. Strategies were categorised into anticipatory (in advance of anticipated pressures) and on the day. The dynamic and unpredictable demands on ICUs meant that strategies were mostly deployed on the day, most commonly by flexing staff, prioritisation of patients and tasks and increasing modes of communication and support.

CONCLUSIONS

ICU staff use a wide variety of adaptive strategies at times of pressure to minimise risk and maintain a reasonable standard of care for patients. These findings provide the foundation for a portfolio of strategies, which can be flexibly employed when under pressure. There is considerable potential for training clinical leaders and teams in the effective use of adaptive strategies.

Limiting life-sustaining treatment for very old ICU patients: cultural challenges and diverse practices

BACKGROUND

Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies.

METHODS

Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems.

RESULTS

This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries.

CONCLUSIONS

This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.

Frequency, Predictors, and Outcomes of the Potential Drug-Drug Interactions in the ICUs of Teaching Hospitals in Ardabil, Northwest of Iran During 2019-2020

Introduction: Drug-drug interactions (DDIs) can reduce therapeutic efficacy and increase the duration and cost of hospitalization so that patients are sometimes exposed to significant complications and even death. Patients in the intensive care unit (ICU) are at higher risk of DDIs for a variety of reasons, including impaired absorption, decreased metabolism, and renal failure. The main objective of this study was to evaluate frequency, clinical ranking and risk factors of potential DDIs in the ICUs of 3 teaching hospitals in Ardabil. Methods: In this descriptive-analytical cross-sectional study, drug prescriptions 355 patients admitted to the ICUs were studied. Patient information including age, sex, diagnosis, number of prescribers, number of drugs, length of stay, and status of patients' discharge (recovery or death) were recorded and checked using the online software up to date and the book Drug Interaction Facts. Finally, the data were statistically analyzed using the SPSS software. Results: The number of patients studied was 355. The mean age of the patients were 51.88 ± 23.22 years, and on average, 8.45 drugs had been prescribed for each patient. The total number of DDIs was 1597 among which class X was 1.4%, class D was 26.2%, and class C was 67.7%. Four hundred ninety-seven unique pairs of DDIs were identified. Age, number of prescribed drugs and length of stay in ICU were associated with prevalence of DDIs. Age and number of drugs were also identified as the risk factors of patients' discharge caused by death. Conclusion: DDIs can complicate health state of patients in ICUs and may increase the length of hospital stay. Setting up computerized systems to alert drug interactions in hospital wards and pharmacotherapeutic intervention by clinical pharmacist can minimize DDIs.

Home care nurses' and managers' work environment during the Covid-19 pandemic: Increased workload, competing demands, and unsustainable trade-offs

Little research exists on how home care nursing personnel have experienced the Covid-19 pandemic. This qualitative study explores the work environment related challenges nurses and managers in home care faced during the pandemic. We discuss these challenges in relation to the Demand-Control-Support Model and reflect on how the organizational dynamics associated with them can be understood using the competing pressures model. During the pandemic, home care nurses and managers experienced both an increased workload and psychosocial strain. For managers, the increased complexity of work was a major problem. We identify three key takeaways related to sustainable crisis management: 1) to support managers' ability to provide social support to their personnel, 2) to increase crisis communication preparedness, and 3) to apply a holistic perspective on protective gear use. We also conclude that the competing pressures model is useful when exploring the dynamics of the work environment in complex organizational contexts.

The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU

BACKGROUND

Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU.

METHODS

This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST.

RESULTS

The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables.

CONCLUSIONS

Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.

Short- and long-term strategies for navigating research-ambivalent organizational cultures besetting embedded researchers

Many health systems may host embedded researchers (ERs) and provide fiscal resources to encourage health service research. However, ERs may remain challenged to initiate research in these settings. This discussion examines how health system culture may impede research initiation, thereby exposing a paradox for embedded researchers immersed in research-ambivalent health systems. The discussion ultimately describes potential short-term and long-term strategies embedded researchers may employ to initiate scholarly inquiry in research-ambivalent health systems.

Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care

BACKGROUND

Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making.

METHODS

Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions.

RESULTS

Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree.

CONCLUSIONS

Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required.

TRIAL REGISTRATION

VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).

Goal Conflicts, Classical Management and Constructivism: How Operators Get Things Done

In this study we identify the differences in goal realisation when applying two conflicting paradigms regarding rule perception and management. We gathered more than 30 scenarios where goal conflicts were apparent in a military operational unit. We found that operators repetitively utilized certain routines in executing their tasks in an effort to realize several conflicting goals. These routines were not originally intended nor designed into the rules and not explicitly included in documentation. They were not necessarily at odds with the literal wording and/or the intent of rules and regulations, although we did find examples of this. Our data showed that local ingenuity was created innovatively within the frame of existing rules or kept invisible to those outside the unit. The routines were introduced and passed on informally, and we found no evidence of testing for the introduction of new risks, no migration into the knowledge base of the organisation, and no dissemination as new best practices. An explanation for this phenomenon was found in the fact that the military organisation was applying a top-down, classical, rational approach to rules. In contrast, the routines were generated by adopting a constructivist view of rules as dynamic, local, situated constructions with operators as experts. The results of this study suggest that organisations are more effective in solving goal conflicts and creating transparency on local ingenuity if they adopt a constructivist paradigm instead of, or together with, a classical paradigm.

Capturing challenges and trade-offs in healthcare work using the pressures diagram: An ethnographic study

Healthcare workers must balance competing priorities to deliver high-quality patient care. Rasmussen's Dynamic Safety Model proposed three factors that organisations must balance to maintain acceptable performance, but there has been little empirical exploration of these ideas, and little is known about the risk trade-offs workers make in practice. The aim of this study was to investigate the different pressures that healthcare workers experience, what risk trade-off decisions they make in response to pressures, and to analyse the implications for quality and safety. The study involved 88.5 h of ethnographic observations at a large, teaching hospital in central London. The analysis revealed five distinct categories of hospital pressures faced by healthcare workers: efficiency, organisational, workload, personal, and quality and safety pressures. Workers most often traded-off workload, personal, and quality and safety pressures to accommodate system-level priorities. The Pressures Diagram was developed to visualise risk trade-offs and prioritising decisions and to facilitate communication about these aspects of healthcare work.

At the end: A vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit

BACKGROUND

Decision-making on end-of-life is an inevitable, yet highly complex, aspect of intensive care decision-making. End-of-life decisions can be challenging both in terms of clinical judgement and social interaction with families, and these two processes often become intertwined. This is especially apparent at times when clinicians are required to seek the views of surrogate decision makers (i.e., family members) when considering palliative care.

METHODS

Using a vignette-based interview methodology, we explored how interactions with family members influence end-of-life decisions by intensive care unit clinicians (n = 24), and identified strategies for reaching consensus with families during this highly emotional phase of care.

RESULTS

We found that the enactment of end-of-life decisions were reported as being affected by a form of loss aversion, whereby concerns over the consequences of not reaching a consensus with families weighed heavily in the minds of clinicians. Fear of conflict with families tended to arise from anticipated unrealistic family expectations of care, family normalization of patient incapacity, and belief systems that prohibit end-of-life decision-making.

CONCLUSIONS

To support decision makers in reaching consensus, various strategies for effective, coherent, and targeted communication (e.g., on patient deterioration and limits of clinical treatment) were suggested as ways to effectively consult with families on end-of-life decision-making.

Digital technologies: An exploratory study of their role in the resilience of healthcare services

Descriptions of resilient performance in healthcare services usually emphasize the role of skills and knowledge of caregivers. At the same time, the human factors discipline often frames digital technologies as sources of brittleness. This paper presents an exploratory investigation of the upside of ten digital technologies derived from Healthcare 4.0 (H4.0) in terms of their perceived contribution to six healthcare services and the four abilities of resilient healthcare: monitor, anticipate, respond, and learn. This contribution was assessed through a multinational survey conducted with 109 experts. Emergency rooms (ERs) and intensive care units (ICUs) stood out as the most benefited by H4.0 technologies. That is consistent with the high complexity of those services, which demand resilient performance. Four H4.0 technologies were top ranked regarding their impacts on the resilience of those services. They are further explored in follow-up interviews with ER and ICU professionals from hospitals in emerging and developed economies to collect examples of applications in their routines.

A digital tumor board solution impacts case discussion time and postponement of cases in tumor boards

Multidisciplinary tumor boards (TBs) is an integral part of cancer care. Emerging evidence shows that effective TB implementation is crucial. It remains largely unknown how digital solutions can assist effective TB conduction. This study aimed to evaluate the impact of a digital solution on case discussion during TB meetings in four cancer types: Breast, Gastrointestinal (GI), Ear, Nose & Throat (ENT), and Hematopathology. A prospective study was performed to evaluate case discussion time during TB meetings pre- and post-solution implementation, at an US academic healthcare cancer center. Data were recorded by a Nurse Navigator for each case during TB meetings. Case discussion times were recorded for 2312 patients, at a total of 286 TB meetings. Significant decreases were observed in the average case discussion time for the breast and GI TBs. We observed a trend for reduction in discussion time variance for all TBs, suggesting the potential of the digital solution to standardize case discussion via provision of uniform case presentation and data access. Postponement rate decreased from 23 to 10% for ENT TB. This study demonstrated that the digital solution enhanced effective TB implementation, with heterogeneity across cancer types.

Resilient trade-offs between safety and profitability: perspectives of sharp-end drivers in the Beijing taxi service system

Background. Trade-offs are common behaviors of resilient systems, when the systems adapt to changing situations to meet multiple goals. Objective. In the context of the Beijing taxi service system (BTSS), this work investigates the sharp-end taxi drivers' trade-offs between work safety and business profitability, demonstrates their resilience in balancing these two goals and identifies factors that contribute to the trade-offs. Methods. An empirical framework incorporating questionnaire surveys, semi-structured interviews, field observation, data screening and categorization was adopted. Data were collected from a random sample of 70 taxi drivers. Results. In the drivers' decisions we found a slight bias in favor of profitability rather than safety (regardless of their finances), and a high level of resilience that the drivers had developed in making strategies for the trade-offs. Trip distance, possibility of traffic congestion, redundant consumption, weather conditions, road features and real-time broadcast information were identified as determinants of the drivers' decision-making. Conclusion. The findings inform BTSS organizational layers and regulators about the sharp-end drivers' needs for productive safety, and provide an evidence base for making more definitive recommendations about support provision and resource re-allocation in an effective and proactive manner.

Going home to die from critical care: A case study

Much of the activity in critical care is complex but repetitive. In order to standardize care and maintain safety, delivery of care is often directed by protocols and care bundles. This case study will reflect on an instance where care transcended the standard protocol-directed path to be more individualized, creative and compassionate. Acts like these can be unique for the practitioners involved and require an element of positive risk taking, which happened here. It will look at the decision-making, planning and risk involved in preparing for a terminally ill patient, who was inotrope and high-flow oxygen dependent, to go home to have treatment withdrawn there instead of in the hospital. This was to fulfil his wish to die at home. In unpicking the circumstances where this positive risk taking led to the desired outcome and the relationship between safety, uncertainty and risk, three themes arose. These were the journey to safe uncertainty; decision-making with uncertain outcomes; and the importance of robust human factors, particularly effective communication and inter-professional teamwork. If positive risk taking can result in enhanced outcomes for the patient, then the question of how this behaviour can be fostered and encouraged must be addressed.

Do multidisciplinary cancer care teams suffer decision-making fatigue: an observational, longitudinal team improvement study

OBJECTIVE

The objective of this study was to examine effectiveness of codesigned quality-improving interventions with a multidisciplinary team (MDT) with high workload and prolonged meetings to ascertain: (1) presence and impact of decision-making (DM) fatigue on team performance in the weekly MDT meeting and (2) impact of a short meeting break as a countermeasure of DM fatigue.

DESIGN AND INTERVENTIONS

This is a longitudinal multiphase study with a codesigned intervention bundle assessed within team audit and feedback cycles. The interventions comprised short meeting breaks, as well as change of room layout and appointing a meeting chair.

SETTING AND PARTICIPANTS

A breast cancer MDT with 15 members was recruited between 2013 and 2015 from a teaching hospital of the London (UK) metropolitan area.

MEASURES

A validated observational tool (Metric for the Observation of Decision-making) was used by trained raters to assess quality of DM during 1335 patient reviews. The tool scores quality of information and team contributions to reviews by individual disciplines (Likert-based scores), which represent our two primary outcome measures.

RESULTS

Data were analysed using multivariate analysis of variance. DM fatigue was present in the MDT meetings: quality of information (M=16.36 to M=15.10) and contribution scores (M=27.67 to M=21.52) declined from first to second half of meetings at baseline. Of the improvement bundle, we found breaks reduced the effect of fatigue: following introduction of breaks (but not other interventions) information quality remained stable between first and second half of meetings (M=16.00 to M=15.94), and contributions to team DM improved overall (M=17.66 to M=19.85).

CONCLUSION

Quality of cancer team DM is affected by fatigue due to sequential case review over often prolonged periods of time. This detrimental effect can be reversed by introducing a break in the middle of the meeting. The study offers a methodology based on 'team audit and feedback' principle for codesigning interventions to improve teamwork in cancer care.

Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England

Background

Risk aversion among junior doctors that manifests as greater intervention (ordering of tests, diagnostic procedures and so on) has been proposed as one of the possible causes for increased pressure in emergency departments (EDs). Here we tested the prediction that doctors with more experience would be more tolerant of uncertainty and therefore less risk-averse in decision making.

Methods

In this cross-sectional, vignette-based study, doctors working in three EDs were asked to complete a questionnaire measuring experience (length of service in EDs), reactions to uncertainty (Gerrity et al, 1995) and risk aversion (responses about the appropriateness of patient management decisions).

Results

Data from 90 doctors were analysed. Doctors had worked in the ED for between 5 weeks and 21 years. We found a large association between experience and risk aversion so that more experienced clinicians made less risk-averse decisions (r=0.47, p<0.001). We also found a large association between experience and reactions to uncertainty (r=−0.50, p<0.001), with more experienced doctors being much more at ease with uncertainty. Mediation analyses indicated that tolerance of uncertainty partially mediated the relationship between experience and lower risk aversion, explaining about a quarter of the effect.

Conclusion

While we might be tempted to conclude from this research that experience and the ability to tolerate uncertainty lead to positive outcomes for patients (less risk-averse management strategies and higher levels of safety netting), what we are unable to conclude from this design is that these less risk-averse strategies improve patient safety.

Intensive care decision-making: Identifying the challenges and generating solutions to improve inter-specialty referrals to critical care

Introduction

Decision-making regarding admission to UK intensive care units is challenging. Demand for beds exceeds capacity, yet the need to provide emergency cover creates pressure to build redundancy into the system. Guidelines to aid clinical decision-making are outdated, resulting in an over-reliance on professional judgement. Although clinicians are highly skilled, there is variability in intensive care unit decision-making, especially at the inter-specialty level wherein cognitive biases contribute to disagreement.

Method

This research is the first to explore intensive care unit referral and admission decision-making using the Critical Decision Method interviewing technique. We interviewed intensive care unit (n = 9) and non-intensive care unit (n = 6) consultants about a challenging referral they had dealt with in the past where there was disagreement about the patient's suitability for intensive care unit.

Results

We present: (i) a description of the referral pathway; (ii) challenges that appear to derail referrals (i.e. process issues, decision biases, inherent stressors, post-decision consequences) and (iii) potential solutions to improve this process.

Discussion

This research provides a foundation upon which interventions to improve inter-specialty decision-making can be based.