Patients who want their family and physician to make resuscitation decisions for them: observations from SUPPORT and HELP. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Hospitalized Elderly Longitudinal Project

Perspective; recommendations for improved patient participation in decision-making for geriatric patients in acute surgical settings

Geriatric patients often present to the hospital in acute surgical settings. In these settings, shared decision-making as equal partners can be challenging. Surgeons should recognize that geriatric patients, and frail patients in particular, may sometimes benefit from de-escalation of care in a palliative setting rather than curative treatment. To provide more person-centred care, better strategies for improved shared decision-making need to be developed and implemented in clinical practice. A shift in thinking from a disease-oriented paradigm to a patient-goal-oriented paradigm is required to provide better person-centred care for older patients. We may greatly improve the collaboration with patients if we move parts of the decision-making process to the pre-acute phase. In the pre-acute phase appointing legal representatives, having goals of care conversations, and advance care planning can help give physicians an idea of what is important to the patient in acute settings. When making decisions as equal partners is not possible, a greater degree of physician responsibility may be appropriate. Physicians should tailor the "sharedness" of the decision-making process to the needs of the patient and their family.

Non-beneficial admission to the intensive care unit: A nationwide survey of practices

INTRODUCTION

In a nationwide survey of practices, we sought to define the criteria, circumstances and consequences of non-beneficial admissions to the intensive care unit (ICU), with a view to proposing measures to avoid such situations.

METHODS

ICU physicians from a French research in ethics network participated in an online survey. The first part recorded age, sex, and years' experience of the participants. In the second part, there were 8 to 12 proposals on each of 4 main domains: (1) What criteria could be used to qualify an ICU stay as non-beneficial? (2) What circumstances result in the admission of a patient whose ICU stay may later be deemed non-beneficial? (3) What are the consequences of a non-beneficial stay in the ICU? (4) What measures could be implemented to avoid admissions that later come to be considered as non-beneficial? Responses were on a 5-point Likert scale ranging from "Strongly disagree" to "Strongly agree".

RESULTS

Among 164 physicians contacted, 154 (94%) responded. The majority cited several criteria used to qualify a stay as non-beneficial. Similarly, >80% cited several possible circumstances that could result in non-beneficial admissions, including lack of knowledge of the case and the patient's history, and failure to anticipate acute deterioration. Possible consequences of non-beneficial stays included stress and anxiety for the patient/family, misunderstandings and conflict. Discussing the utility of possible ICU admission in the framework of the patient's overall healthcare goals was hailed as a means to prevent non-beneficial admissions.

CONCLUSION

The results of this survey suggest that joint discussions should take place during the patient's healthcare trajectory, before the acute need for ICU arises, with a view to limiting or avoiding ICU stays that may later come to be deemed "non-beneficial".

Escalation and Withdrawal of Treatment for Patients on Extracorporeal Membrane Oxygenation: A Qualitative Study

OBJECTIVE

The aim of this study was to describe decisions about the escalation and withdrawal of treatment for patients on extracorporeal membrane oxygenation (ECMO).

SUMMARY BACKGROUND DATA

Interventions premised on facilitating patient autonomy have proven problematic in guiding treatment decisions in intensive care units (ICUs). Calls have thus been made to better understand how decisions are made in critical care. ECMO is an important form of cardiac and respiratory support, but care on ECMO is characterized by prognostic uncertainty, varying time course, and high resource use. It remains unclear how decisions about treatment escalation and withdrawal should be made for patients on ECMO and what role families should play in these decisions.

METHODS

We performed a focused ethnography in 2 cardiothoracic ICUs in 2 US academic hospitals. We conducted 380 hours of observation, 34 weekly interviews with families of 20 ECMO patients, and 13 interviews with unit clinicians from January to September 2018. Qualitative analysis used an iterative coding process.

RESULTS

Following ECMO initiation, treatment was escalated as complications mounted until the patient either could be decannulated or interventional options were exhausted. Families were well-informed about treatment and prognosis but played minimal roles in shaping the trajectory of care.

CONCLUSIONS

Discussion between clinicians and families about prognosis and goals was frequent but did not occasion decision-making moments. This study helps explain why communication interventions intended to maintain patient autonomy through facilitating surrogate participation in decisions have had limited impact. A more comprehensive understanding of upstream factors that predispose courses of critical care is needed.

Family members' perceptions of surrogate decision-making in the intensive care unit: A systematic review

BACKGROUND

A better understanding of the perceptions of family members in making surrogate decisions for loved ones during intensive care is needed to inform the development of targeted supportive interventions.

OBJECTIVE

To examine and synthesize qualitative data on family members' perceptions of surrogate decision-making in the intensive care unit.

DESIGN

We conducted a systematic review and qualitative data synthesis. Eligible studies contained family members' quotes about surrogate decision-making experiences and perceptions in adult intensive care units, published in English or Chinese, in a peer-reviewed journal up to February 2022. Data sources included Embase, PubMed, ISI Web of Science, PsychINFO, CINAHL, Biomedical Literature Service System, China National Knowledge Infrastructure (CNKI), Wanfang Data, and VIP Journal.

METHODS

The searches yielded 5974 identified articles, of which 23 studies were included. At least two different reviewers independently assessed the study quality and extracted data into a Microsoft Excel spreadsheet. A thematic synthesis was performed by classifying all text units into one of the broad themes and subsequently analyzed to inductively develop the first-, second-, and third-order themes. Six family members with experience in intensive care unit surrogate decision-making contributed to the analysis.

RESULTS

The qualitative data synthesis resulted in five major themes. The following key new insights into family members' perceptions of surrogate decision-making in the intensive care unit were obtained: in individual systems, family members suffered from emotional distress and psychological stress; different cognitive styles emerged; some family members reshaped a new order of life in the disruption; in family systems, the family as a whole was closely connected with each other; and in medical systems families perceived asymmetry in relationships with clinicians, many factors influencing trust, the necessity for role-specific mediators and issues with operations and environments not being sufficiently humanized.

CONCLUSION

This qualitative synthesis showed that individuals' emotions and cognition underwent complex processes during surrogate decision-making. The family as a whole, with disparate functional states, also faced different processes and outcomes under the crisis situation. At a broader level, the decision-making process reflected society's perceptions of the medical system. Future studies should use these insights to further explore and optimize the many aspects of surrogate decision support measures for families of critically ill patients and include the measurement of outcomes after interventions at multiple layers of the individual, family, and medical systems.

REGISTRATION NUMBER

The protocol was prospectively published on International Prospective Register of Systematic Reviews (PROSPERO)-CRD42022316687.

TWEETABLE ABSTRACT

Families of critically ill patients undergo a complex interactional process within the individual, family, and medical systems during surrogate decision-making.

Informing the standardising of care for prolonged stay patients in the intensive care unit: A scoping review of quality improvement tools

OBJECTIVES

To inform design of quality improvement tools specific to patients with prolonged intensive care unit stay, we determined characteristics (format/content), development, implementation and outcomes of published multi-component quality improvement tools used in the intenisve care unit irrespective of length of stay.

RESEARCH METHODOLOGY

Scoping review searching electronic databases, trial registries and grey literature (January 2000 to January 2022).

RESULTS

We screened 58,378 citations, identifying 96 studies. All tools were designed for use commencing at intensive care unit admission except three tools implemented at 3, 5 or 14 days. We identified 32 studies of locally developed checklists, 28 goal setting/structured communication templates, 23 care bundles and 9 studies of mixed format tools. Most (43 %) tools were designed for use during rounds, fewer tools were designed for use throughout the ICU day (27 %) or stay (9 %). Most studies (55 %) reported process objectives i.e., improving communication, care standardisation, or rounding efficiency. Most common clinical processes quality improvement tools were used to standardise were sedation (62, 65 %), ventilation and weaning (55, 57 %) and analgesia management (58, 60 %). 44 studies reported the effect of the tool on patient outcomes. Of these, only two identified a negative effect; increased length of stay and increased days with pain and delirium.

CONCLUSION

Although we identified numerous quality improvement tools for use in the intensive care unit, few were designed to specifically address actionable processes of care relevant to the unique needs of prolonged stay patients. Tools that address these needs are urgently required.

SYSTEMATIC REVIEW REGISTRATION

The review protocol is registered on the Open Science Framework, https://osf.io/, DOI 10.17605/OSF.IO/Z8MRE.

Advance Directives in Oncology and Haematology: A Long Way to Go-A Narrative Review

Patients living with cancer often experience serious adverse events due to their condition or its treatments. Those events may lead to a critical care unit admission or even result in death. One of the most important but challenging parts of care is to build a care plan according to the patient’s wishes, meeting their goals and values. Advance directives (ADs) allow everyone to give their preferences in advance regarding life sustaining treatments, continuation, and withdrawal or withholding of treatments in case one is not able to speak their mind anymore. While the absence of ADs is associated with a greater probability of receiving unwanted intensive care around the end of their life, their existence correlates with the respect of the patient’s desires and their greater satisfaction. Although progress has been made to promote ADs’ completion, they are still scarcely used among cancer patients in many countries. Several limitations to their acceptance and use can be detected. Efforts should be made to provide tailored solutions for the identified hindrances. This narrative review aims to depict the situation of ADs in the oncology context, and to highlight the future areas of improvement.

"She's Not Ready to Give Up Yet!": When a Family Member Overrides the Patient's Medical Decisions

Autonomy, which gives individuals the right to make informed decisions about their medical treatment, is a central principle in Western bioethics. However, we often encounter patients for whom a family member seems to dominate medical decision-making, to the extent that clinicians become concerned that the patient is subject to excessive pressure or even coercion. In this article, we describe one such case and how we assess a decision-making process that involves family influence. This entails acknowledging that many individuals weigh their family members' preferences and/or well-being heavily in making medical decisions, and family norms for decision-making differ. A family member who tells their loved one "You can't give up now" is typically not ursurping the patient's liberty to make a different decision. However, there are some family influences which may be autonomy-limiting, including credible threats, or in situations of abuse. Aside from these scenarios, our role is not to alter a couple's long-standing dynamics and decision-making processes. However, for the patient who wants to assert herself, we can set the stage in a family meeting and amplify her voice. We must also attend to the emotional level of family members' statements. "I won't let you give up" might be more a statement of grief rather than a true reflection of their values or intent. Supporting the family member's coping may help to bring together what initially seem to be divergent goals. Exploring these decision-making dynamics is key to providing good palliative care.

Defining Familial Interactions and Networks: An Exploratory Qualitative Study on Family Networks and Surrogate Decision-Making

Supplemental Digital Content is available in the text.

OBJECTIVES:

To characterize patient preferences for medical surrogate decision-makers in the ICU to capture the complexity of decision-making preferences and highlight potential conflicts between patients’ preferences and clinicians’ surrogate decision-maker identification in usual clinical practice.

DESIGN:

Prospective qualitative cross-sectional study.

SETTING:

Two ICUs in a quaternary referral center in the eastern United States.

PATIENTS:

Convenience sample of patients admitted to the ICU and their family members.

INTERVENTION:

None.

MEASUREMENTS AND MAIN RESULTS:

Twenty-six patient-family-clinician units were interviewed. Men were three times more likely than women to have a legally appointed decision-maker that matched their preferred decision-maker as expressed in the interview. Patients who were married or in a long-term relationship were the most consistent group of respondents, with 94% of them selecting their spouse or partner as the preferred decision-maker. The most common reasons for selecting a surrogate decision-maker were intangible themes such as feeling “known” by that person rather than having prior discussions about specific wishes or advance directives.

CONCLUSIONS:

Asking about a patient’s familial network and qualities they value in a surrogate decision-maker may aid ICU teams in honoring patients’ wishes for surrogate decision-making. This may be an important supplement to accepted legal hierarchies for proxy decision-makers and advance directive documents. Further studies with larger sample sizes could be used to shed light on the nuances of familial and relationship networks of a more diverse population of respondents.

Psychological Symptoms in Relatives of Critically Ill Patients: A Longitudinal Cohort Study

OBJECTIVES

To explore the psychologic impact of an ICU stay on relatives and to determine patient and relative factors, including their pre-ICU mental health status, associated with psychologic symptoms 3 months after ICU admission.

DESIGN

A prospective, exploratory, longitudinal cohort study.

SETTING

A 12-bed ICU in a Dutch tertiary teaching hospital.

PATIENTS

The relatives of ICU patients admitted between March 2018 and December 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Relatives completed the Hospital Anxiety and Depression Scale shortly after patients' ICU admission referring to the week before ICU admission and 3 months later, together with the Impact of Event Scale-Revised, assessing posttraumatic stress. A total of 387 were eligible of which 78 (20%) responded. Almost a quarter reported an increase of anxiety (23.1%) and depression (24.4%) between baseline and 3 months follow-up. One in six (17.9%) reported posttraumatic stress. Anxiety, depression, and posttraumatic stress at 3 months follow-up were significantly associated with preexisting anxiety and depression. Patients' factor associated with depression 3 months follow-up in relatives was length of ICU stay (odds ratio, 1.09; 95% CI, 1.02-1.16).

CONCLUSIONS

Relatives with preexisting psychologic symptoms before ICU admission are at risk to develop anxiety, depression, or posttraumatic stress shortly after ICU discharge of the patient. Screening and identification in an early stage enables early interventions to prevent relatives from worsening mental health during and after ICU admission.

The differences in nurses' willingness to discuss palliative care with patients and their family members

BACKGROUND

This study aimed to evaluate the differences in nurses' willingness to discuss palliative care with terminally ill patients and their family members.

METHODS

The participants were randomly recruited from registered staff nurses ≥20 years of age who were responsible for clinical inpatient care in a tertiary hospital in northern Taiwan. A semi-structured questionnaire was administered to evaluate nurses' experiences of discussing do-not-resuscitate (DNR) decisions and their willingness to discuss palliative care with terminal patients and their family members. The differences in nurses' experiences regarding DNR and willingness to discuss palliative care with terminally ill patients and their family members were compared using the Chi-square test. Logistic regressions were used to analyze factors associated with nurses' willingness to discuss palliative care with patients and their families.

RESULTS

More participants had experienced initiating discussions about DNR with patients' families than with patients (72.2% vs 61.9%, p < 0.001). Unadjusted logistic regression analysis showed that the experiences of actively initiating DNR discussions with patients were a significant factor associated with palliative care discussion with patients (odds ratio [OR] = 2.91, 95% confidence interval [CI]: 1.09-7.79). On the other hand, the experiences of actively initiating DNR discussions with patients and with patients' families were significant factors associated with palliative care discussion with patients' families (OR = 3.84, 95% CI: 1.22-12.06 and OR = 3.60, 95% CI: 1.19-10.90, respectively). After adjusting for covariates, no significant factors were found to be independently associated with nurses' willingness to discuss palliative care with patients and their family members.

CONCLUSION

There are significant differences in nurses' willingness to discuss palliative care with patients and their family members. Further research is needed to evaluate factors associated with nurses' willingness to discuss palliative care with patients and their families to facilitate these discussions and protect patients' autonomy.

Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life

IMPORTANCE

Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations.

OBJECTIVES

To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system.

EXPOSURES

POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury.

MAIN OUTCOMES AND MEASURES

The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life.

RESULTS

Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]).

CONCLUSIONS AND RELEVANCE

Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.

The Ethics of Surgery at End of Life

The role of the anesthesiologist cannot be understated when it comes to ethical decision making, especially at end of life. To best serve patients within the limits of the law, anesthesiologists must arm themselves with an understanding of how the laws surrounding ethical decision-making impact daily practices. It is also important to know what rights and duties a patient or surrogate has in the decision-making process. With proper understanding of their responsibilities and the available tools, anesthesiologists can fulfill their roles as leaders and advocates for their patients as approaches to ethical decision-making at the end of life evolve.

Do medical oncology patients and their support persons agree about end-of-life issues?

BACKGROUND

The perceptions of those called on to make decisions on behalf of patients who lack capacity at the end of life must accurately reflect patient preferences.

AIMS

To establish the extent to which the views of medical oncology outpatients are understood by their support persons, specifically with regards to (i) preferred type and location of end-of-life care, (ii) preferred level of involvement in end-of-life decision-making and (iii) whether the patient has completed an advance care plan or appointed an enduring guardian.

METHODS

Adults with a confirmed cancer diagnosis and their nominated support persons were approached between September 2015 and January 2016 in the waiting room of an Australian tertiary referral clinic. Consenting participants completed a pen-and-paper survey. Nominated support persons answered the same questions from the patient's perspective.

RESULTS

In total, 208 participants (39% of eligible dyads) participated. Observed agreement across the five outcomes ranged from 54% to 84%. Kappa values for concordance between patient-support person responses were fair to moderate (0.24-0.47) for enduring guardian, decision-making, advance care plan and care location outcomes. A slight level of concordance (k = 0.15; 95% confidence interval: -0.02, 0.32) was found for the type of care outcome.

CONCLUSION

Relying on support persons' views does not guarantee that patients' actual preferences will be followed. Strategies that make patient preferences known to healthcare providers and support persons while they still have the capacity to do so is a critical next step in improving quality cancer care.

Ethical challenges in resuscitation

PURPOSE

A rapidly evolving resuscitation science provides more effective treatments to an aging population with multiple comorbidites. Concurrently, emergency care has become patient-centered. This review aims to describe challenges associated with the application of key principles of bioethics in resuscitation and post-resuscitation care; propose actions to address these challenges; and highlight the need for evidence-based ethics and consensus on ethical principles interpretation.

METHODS

Following agreement on the article's outline, subgroups of 2-3 authors provided narrative reviews of ethical issues concerning autonomy and honesty, beneficence/nonmaleficence and dignity, justice, specific practices/circumstances such as family presence during resuscitation, and emergency research. Proposals for addressing ethical challenges were also offered.

RESULTS

Respect for patient autonomy can be realized through honest provision of information, shared decision-making, and advance directives/care planning. Essential prerequisites comprise public and specific healthcare professionals' education, appropriate regulatory provisions, and allocation of adequate resources. Regarding beneficence/nonmaleficence, resuscitation should benefit patients, while avoiding harm from futile interventions; pertinent practice should be based on neurological prognostication and patient/family-reported outcomes. Regarding dignity, aggressive life-sustaining treatments against patients preferences should be avoided. Contrary to the principle of justice, resuscitation quality may be affected by race/income status, age, ethnicity, comorbidity, and location (urban versus rural or country-specific/region-specific). Current evidence supports family presence during resuscitation. Regarding emergency research, autonomy should be respected without hindering scientific progress; furthermore, transparency of research conduct should be promoted and funding increased.

CONCLUSIONS

Major ethical challenges in resuscitation science need to be addressed through complex/resource-demanding interventions. Such actions require support by ongoing/future research.

The second patient? Family members of cancer patients and their role in end-of-life decision making

BACKGROUND

Family members are important companions of severely ill patients with cancer. However, studies about the desirability and difficulties of integrating relatives in the decision-making process are rare in oncology. This qualitative study explores the family role in decisions to limit treatment near the end of life from the professionals' point of view.

METHODS

Qualitative in-depth interviews were conducted with oncologists (n = 12) and nurses (n = 6) working at the Department of Hematology/Oncology at the University Hospital in Munich, Germany. The data were analyzed using a descriptive qualitative methodology and discussed from a medical ethics perspective.

RESULTS

Four major themes played a central role in the perception of the medical staff in regard to family members. (1) Family impact on patients' treatment preferences. (2) Strong family wish for further treatment. (3) Emotional distress of the family related to the involvement in end-of-life decision-making. (4) Importance of knowing family structures.

CONCLUSIONS

The important role of the family members in patients' disease process is recognized by oncologists and oncology nurses. However, this does not seem to lead to an early involvement of the family members. Developing and establishing a systematic assessment of family members' needs and wishes in order to provide a specific-tailored support should become a priority for interdisciplinary clinical research in the near future.

The Experience of Surrogate Decision Makers on Being Approached for Consent for Patient Participation in Research. A Multicenter Study

RATIONALE

Recruitment in critical care research differs from other contexts in important ways: patients lack decision-making capacity, uncertainty exists regarding patient prognosis, and critical illnesses are often associated with appreciable morbidity and mortality.

OBJECTIVES

We aimed to describe the experiences of surrogate decision makers (SDMs) in being approached for consent for critically ill patients to participate in research.

METHODS

A multicenter, qualitative study involving semistructured interviews with 26 SDMs, who provided or declined surrogate consent for research participation, at 5 Canadian centers nested within a multicenter observational study of research recruitment practices. Transcripts were reviewed by three qualitative researchers, and data were analyzed using grounded theory and a narrative critical analysis.

MEASUREMENTS AND MAIN RESULTS

SDMs were guided by an overarching desire for the patient to live. Surrogate research decision-making involved three sequential stages: (1) being approached; (2) reflecting on participation; and (3) making a decision. In stage 1, SDMs identified factors (their expectations, how they were approached, the attributes of the person approaching, and study risks and benefits) that characterized their consent encounter and affirmed a preference to be approached in person. If SDMs perceived the risk of participation to be too high or felt patients may not benefit from participation, they did not contemplate further. In stage 2, SDMs who knew the patient's wishes or had a deeper understanding of research prioritized the patient's wishes and the perceived benefits of participation. Without this information, SDMs prioritized obtaining more and better care for the patient, considered what was in their mutual best interests, and valued healthcare professional's knowledge. Trust in healthcare professionals was essential to proceeding further. In stage 3, SDMs considered six factors in rendering decisions.

CONCLUSIONS

SDMs engaged in three sequential stages and considered six factors in making surrogate decisions for research participation. Surrogates' assessments of the risks and benefits of participation and their trust in healthcare professionals were critical factors in research decision-making. By conceptualizing surrogate decision-making for research in stages, future research can develop and test procedures to enhance the surrogate research decision-making process.

What are the ethical questions raised by the integration of intensive care into advance care planning?

A major goal of intensive care units (ICUs) is to offer optimal management, but for many patients admitted to the ICU, they are unlikely to yield any lasting benefit. In this context, the ICU physician remains a key intermediary, particularly when a decision regarding possible limitation or withdrawal of life-sustaining therapy becomes necessary. The possibility of admission to the ICU, and the type of care the patient would like to receive there, should be integrated into the healthcare project in agreement with the patient, regardless of the stage of disease that the patient suffers from. These dispositions should be recorded in the patient's file, and should respect the progressive nature of both the disease itself, and the discussions necessary in such complex situations. The ICU physician can serve as a valuable consultant for the treating physician, in particular to guide patient choices when formalizing their healthcare preferences in the form of advance care planning (ACP) or advance directives (AD). Ideally, the best time to address this issue is before the patient's clinical situation deteriorates towards an acute emergency, and providing complete and transparent information to inform the patient's choices.

Comparison of Methods To Identify Advance Care Planning in Patients with Severe Chronic Obstructive Pulmonary Disease Exacerbation

BACKGROUND

Advance care planning (ACP) is recommended for patients with chronic obstructive pulmonary disease (COPD). Yet, ACP documentation is often inaccessible at the time of impending respiratory failure, which may lead to unwanted and costly medical intensive care unit admissions. Electronic medical records (EMRs) contain directive fields and the ability to search for keywords and phrases, but these strategies to rapidly identify ACP have not been validated.

OBJECTIVES

The aim of this study is to identify the percentage of patients with severe COPD exacerbation who have outpatient ACP documentation and validate two EMR-based methods of rapidly identifying ACP documentation.

DESIGN

Retrospective cohort analysis.

SETTING/SUBJECTS

Patients who required medical intensive care unit admission for exacerbation of COPD at an urban safety-net hospital between 2009 and 2014 were observed.

MEASUREMENTS

We analyzed the sensitivity and specificity of two methods to rapidly identify outpatient ACP documentation: (1) documentation in the EMR directive field and (2) text string search of notes for key phrases, compared with a gold standard clinician review.

RESULTS

Our cohort (n = 311) was racially diverse and severely ill with obstructive lung disease. One hundred thirty-two patients (43%) had ACP documentation by gold standard chart review. Compared with a gold standard chart review, a parsimonious text string search was both sensitive (95%) and specific (97%), while the directive box was specific (100%), but not sensitive (54%), for identifying outpatient ACP documentation.

CONCLUSIONS

EMR directive fields may substantially underestimate ACP when used alone. As full clinician chart reviews are impractical in the emergent setting, text string searches may be a useful strategy to rapidly identify ACP discussions for clinical care and research.

Hospital workers' confidence for end-of-life decisions in their family: A multicenter study

Aims:

To study whether health-care workers feel capable of making resuscitation decisions for their own families, the confidence in their family to represent their own preferences, and if some health-care workers feel greater confidence in their ability to undertake such decisions for their family than others.

Methods:

An anonymous survey conducted among health-care workers of nine institutions in North and Central America. The self-administered questionnaire included demographic and professional characteristics, attitudes, personal preferences, and value judgments on the topic of resuscitation.

Results:

Eight hundred and fifty-eight surveys were completed; 21.1% by physicians, 37.2% by nurses, and 41.7% by other health-care. Most of the health-care workers (83.5%) stated that they should be unable to determine their own code status and they would allow their family or spouse/significant other to make this decision for themselves. Physicians felt significantly more capable of making a decision regarding the code status of a close family member than other hospital workers (P = 0.019). Professionals who chose to not undergo cardiopulmonary resuscitation were less likely to feel capable of determining the code status of their family.

Conclusions:

Most of the health-care workers feel capable of making code status decisions for a close family member and most feel equally comfortable having their family or spouse/significant other represent their code status preference should they be incapacitated. There is considerable reciprocity between the two situations. Physicians feel more confident in their ability to make code status decisions for their loved ones than other health-care workers. Regardless of profession, a personal preference for do not attempt resuscitation status is related to less confidence.

Balancing digital information-sharing and patient privacy when engaging families in the intensive care unit

Patients in intensive care units (ICUs) may lack decisional capacity and may depend on proxy decision makers (PDMs) to make medical decisions on their behalf. High-quality information-sharing with PDMs, including through such means as health information technology, could improve communication and decision making and could potentially minimize the psychological consequences of an ICU stay for both patients and their family members. However, alongside these anticipated benefits of information-sharing are risks of unwanted disclosure of sensitive information. Approaches to identifying the optimal balance between access to digital health information to facilitate engagement and protecting patient privacy are urgently needed. We identified eight themes that should be considered in balancing health information access and patient privacy: 1) potential benefits to patients from PDM data access; 2) potential harms to patients from such access; 3) the moral status of families within the patient-clinician relationship; 4) the scope of relevant information provided to PDMs; 5) issues around defining PDMs' authority; 6) methods for eliciting and documenting patient preferences about their family's information access; 7) the relevance of methods for ascertaining the identity of PDMs; and 8) the obligations of hospitals to prevent privacy breaches by PDMs. We conclude that PDMs should typically have access to health information from the current episode of care when the patient is decisionally impaired, unless the patient has previously expressed a clear preference that PDMs not have such access.

Nurses’ and Physicians’ Opinions on Aggressiveness of Treatment for General Ward Patients

The aim of this study was to evaluate agreement between nurses’ and physicians’ opinions regarding aggressiveness of treatment and to investigate and compare the rationales on which their opinions were based. Structured interviews regarding 714 patients were performed on seven general wards of a university hospital. The data gathered were then subjected to qualitative and quantitative analyses. There was 86% agreement between nurses’ and physicians’ opinions regarding full or limited treatment when the answers given as ‘uncertain’ were excluded. Agreement was less (77%) for patients with a life expectancy of less than one year. Disagreements were not associated with professional status because the physicians considered limiting life-sustaining treatment as often as the nurses. A broad spectrum of rationales was given but the results focus mostly on those for full treatment. The nurses and the physicians had similar bases for their opinions. For the majority of the patients, medical rationales were used, but age and quality of life were also expressed as important determinants. When considering full treatment, nurses used quality-of-life rationales for significantly more patients than the physicians. Respect for patients’ wishes had a minor influence.

Terminally Ill Elderly Patient's Experiences, Attitudes, and Needs: A Qualitative Study

The aim of this qualitative study was to clarify how terminally ill elderly patients in acute wards perceive the end of life and what are their needs and wishes regarding care. The patients, despite their advanced illness, wished to be treated actively and hoped for more conversations with doctors about active care. They were content with their daily care but evaluated the care in light of the great workload of the nurses, forgiving them for not having time to talk to individual patients. They had specific modest wishes, but were reluctant to express even these because of concern about troubling their caregivers. We conclude that death remained a distant abstraction for these patients with a terminal prognosis. The challenge is to create an intimate caring atmosphere, where the issues related to dying may be elaborated in interaction and the last wishes expressed in a safe atmosphere.

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

Background

Cardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.

Aims and objectives

This project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.

Methods

A systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.

Results

The literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.

Limitations

The variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.

Conclusion

There is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.

Future work

Recommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.

Study registration

This study is registered as PROSPERO CRD42012002669.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units

In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.

Easing the burden of surrogate decision making: the role of a do-not-escalate-treatment order

We present a case illustrating the common problem of a surrogate decision maker who is psychologically distressed over the medical team's recommendation to withdraw life-sustaining treatment. We suggest how a do-not-escalate-treatment (DNET) order can be helpful in such situations when the usual approaches to withholding or withdrawing care are not acceptable to the surrogate. We define a DNET order, explain when it might be useful, and discuss how it can facilitate a humane, negotiated resolution of differences.

Cancer in the elderly: is it time for palliative care in geriatric oncology?

BACKGROUND

Persons aged 65 and over are the fastest growing segment of the population in most Western countries. Although cancer-related death occurs far more commonly in older people than in any age group, studies on palliative care in older adults are lacking.

OBJECTIVE

This paper aims at evaluating the needs in elderly patients affected by cancer and the state of the art of the research in palliative care in this setting.

MATERIALS AND METHODS

A literature search was performed (PubMed) to identify relevant studies. Papers were reviewed for relevance to palliative care in the elderly.

RESULTS

Elderly who need palliative care are frequently disregarded as individuals and may experience discrimination because of their age. Palliative care for older patients relates particularly to multiple treatments for various conditions. This causes extra complexities for the researchers.

CONCLUSIONS

The aim of the study was not fully achieved due to the paucity of literature focusing upon these issues. The areas of investigation that need to be addressed comprise: establishing the prevailing symptoms in elderly patients, understanding patients' psychological/spiritual well-being and quality of life and elucidating the sources of caregiver burden, adapting research methodologies specifically for palliative care and comparing the needs and the outcomes of this age group to younger patients.

Improving medical decisions for incapacitated persons: does focusing on "accurate predictions" lead to an inaccurate picture?

The Patient Preference Predictor (PPP) proposal places a high priority on the accuracy of predicting patients' preferences and finds the performance of surrogates inadequate. However, the quest to develop a highly accurate, individualized statistical model has significant obstacles. First, it will be impossible to validate the PPP beyond the limit imposed by 60%-80% reliability of people's preferences for future medical decisions--a figure no better than the known average accuracy of surrogates. Second, evidence supports the view that a sizable minority of persons may not even have preferences to predict. Third, many, perhaps most, people express their autonomy just as much by entrusting their loved ones to exercise their judgment than by desiring to specifically control future decisions. Surrogate decision making faces none of these issues and, in fact, it may be more efficient, accurate, and authoritative than is commonly assumed.

What is a good death? Health care professionals' narrations on end-of-life care

The present study explores how health professionals evaluate care at the end of life and what they consider to be a good death. We conducted four focus groups with 37 health professionals and used a grounded theory-based approach to analyze the transcripts of the discussions. A lack of organization, training, formalized procedures, and communication with dying persons and their families emerged. Difficulty in defining a good death derived from the ethical dilemmas that involved places to die, palliative care, and end-of-life decision making.

Attitude of elderly patients towards cardiopulmonary resuscitation in Greece

AIM

Although researchers in several countries have investigated patients' points of view regarding cardiopulmonary resuscitation, there has been no research investigating this issue in Greece. The present study aimed at identifying the attitude of older Greek patients regarding cardiopulmonary resuscitation.

METHODS

One basic questionnaire consisting of 34 questions was used in order to identify patients' opinions regarding cardiopulmonary resuscitation in five different hospitals from June to November 2011.

RESULTS

In total, 300 questionnaires were collected. Although patients' knowledge regarding cardiopulmonary resuscitation was poor, most of them would like to be resuscitated in case they suffered an in-hospital cardiac arrest. Also, they believe that they should have the right to accept or refuse treatment. However, the legal and sociocultural norms in Greece do not support patients' choice for the decision to refuse resuscitation. The influence of several factors, such as their general health status or the underlying pathology, could lead patients to give a "do not attempt resuscitation" order.

CONCLUSIONS

The attitudes of older Greek patients regarding resuscitation are not different from others', whereas the legal and sociocultural norms in Greece do not support patient choice in end-of-life decisions, namely the decision to refuse resuscitation. We advocate the introduction of advanced directives, as well as the establishment and implementation of specific legislation regarding the ethics of resuscitation in Greece.

Advance care planning beyond advance directives: perspectives from patients and surrogates

CONTEXT

Advance care planning (ACP) has focused on documenting life-sustaining treatment preferences in advance directives (ADs). The ADs alone may be insufficient to prepare diverse patients and surrogates for complex medical decisions.

OBJECTIVES

To understand what steps best prepare patients and surrogates for decision making.

METHODS

We conducted 13 English/Spanish focus groups with participants from a Veterans Affairs and county hospital and the community. Seven groups included patients (n=38), aged ≥65 years, who reported making serious medical decisions. Six separate groups included surrogates (n=31), aged ≥18 years, who made decisions for others. Semistructured focus groups asked what activities best prepared the participants for decision making. Two investigators independently coded data and performed thematic content analysis. Disputes were resolved by consensus.

RESULTS

The mean±SD patient age was 78±8 years, and 61% were nonwhite. The mean±SD surrogate age was 57±10 years, and 91% were nonwhite. Qualitative analysis identified four overarching themes about how to best prepare for decision making: 1) identify values based on past experiences and quality of life, 2) choose surrogates wisely and verify that they understand their role, 3) decide whether to grant leeway in surrogate decision making, and 4) inform other family and friends of one's wishes to prevent conflict.

CONCLUSION

Beyond ADs, patients and surrogates recommend several additional steps to prepare for medical decision making including using past experiences to identify values, verifying that the surrogate understands their role, deciding whether to grant surrogates leeway, and informing other family and friends of one's wishes. Future ACP interventions should consider incorporating these additional ACP activities.

Clinical review: the role of the intensivist and the rapid response team in nosocomial end-of-life care

In-hospital end-of-life care outside the ICU is a new and increasing aspect of practice for intensive care physicians in countries where rapid response teams have been introduced. As more of these patients die from withdrawal or withholding of artificial life support, determining whether a patient is dying or not has become as important to intensivists as the management of organ support therapy itself. Intensivists have now moved to making such decisions in hospital wards outside the boundaries of their usual closely monitored environment. This strategic change may cause concern to some intensivists; however, as custodians of the highest technology area in the hospital, intensivists are by necessity involved in such processes. Now, more than ever before, intensive care clinicians must consider the usefulness of key concepts surrounding nosocomial death and dying and the importance and value of making a formal diagnosis of dying in the wards. In this article, we assess the conceptual background, reference points, challenges and implications of these emerging aspects of intensive care medicine.

How important is 'accuracy' of surrogate decision-making for research participation?

BACKGROUND

There is a longstanding concern about the accuracy of surrogate consent in representing the health care and research preferences of those who lose their ability to decide for themselves. We sought informed, deliberative views of the older general public (≥50 years old) regarding their willingness to participate in dementia research and to grant leeway to future surrogates to choose an option contrary to their stated wishes.

METHODOLOGY/PRINCIPAL FINDINGS

503 persons aged 50+ recruited by random digit dialing were randomly assigned to one of three groups: deliberation, education, or control. The deliberation group attended an all-day education/peer deliberation session; the education group received written information only. Participants were surveyed at baseline, after the deliberation session (or equivalent time), and one month after the session, regarding their willingness to participate in dementia research and to give leeway to surrogates, regarding studies of varying risk-benefit profiles (a lumbar puncture study, a drug randomized controlled trial, a vaccine randomized controlled trial, and an early phase gene transfer trial). At baseline, 48% (gene transfer scenario) to 92% (drug RCT) were willing to participate in future dementia research. A majority of respondents (57-71% depending on scenario) were willing to give leeway to future surrogate decision-makers. Democratic deliberation increased willingness to participate in all scenarios, to grant leeway in 3 of 4 scenarios (lumbar puncture, vaccine, and gene transfer), and to enroll loved ones in research in all scenarios. On average, respondents were more willing to volunteer themselves for research than to enroll their loved ones.

CONCLUSIONS/SIGNIFICANCE

Most people were willing to grant leeway to their surrogates, and this willingness was either sustained or increased after democratic deliberation, suggesting that the attitude toward leeway is a reliable opinion. Eliciting a person's current preferences about future research participation should also involve eliciting his or her leeway preferences.

Medical decision-making for older adults without family

Each year in the United States, individuals who lack decision-making capacity because of acute or chronic cognitive impairment are in situations in which important medical decisions must be made for them, but tens of thousands of these individuals have no known family members or designated surrogates available to help with those decisions. Such individuals constitute 16% of patients in intensive care units, 3% of nursing home residents, and a large but unspecified number of individuals in a variety of settings who are facing end-of-life decisions. Several approaches are currently used to aid in medical decision-making for people without families or designated surrogates, including hospital ethics committees, court-appointed surrogate agents, reliance on advance directives if they are available, and even the use of computer-based decision systems. These approaches all have limitations and often result in individuals receiving care that would not have been their preference. Additionally, because clinical care teams must wrestle with uncertainty about best approaches to care, lengths of hospital stay for individuals without family are longer, resulting in higher healthcare costs and potentially more-aggressive interventions than individuals with family experience. This article reviews medical decision-making for older adults without families or designated surrogates and proposes a solution: "health fiduciaries"--a new type of professional trained and certified to act as a surrogate decision-maker for individuals who are unable to make decisions for themselves.

An overview of end-of-life issues in the intensive care unit

The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.

The need for safeguards in advance care planning

The recent uproar about Medicare "death panels" draws attention to public and professional concerns that advance care planning might restrict access to desired life-sustaining care. The primary goal of advance care planning is to promote the autonomy of a decisionally incapacitated patient when choices about life-sustaining treatments are encountered, but the safety of this procedure has not received deserved scrutiny. Patients often do not understand their decisions or they may change their mind without changing their advance care directives. Likewise, concordance between patients' wishes and the understanding of the physicians and surrogate decision makers who need to represent these wishes is disappointingly poor. A few recent reports show encouraging outcomes from advance care planning, but most studies indicate that the procedure is ineffective in protecting patients from unwanted treatments and may even undermine autonomy by leading to choices that do not reflect patient values, goals, and preferences. Safeguards for advance care planning should be put in place, such as encouraging physicians to err on the side of preserving life when advance care directives are unclear, requiring a trained advisor to review non-emergent patient choices to limit life-sustaining treatment, training of clinicians in conducting such conversations, and structured discussion formats that first address values and goals rather than particular life-sustaining procedures. Key targets for research include: how to improve completion rates for person wanting advance care directives, especially among minorities; more effective and standardized approaches to advance care planning discussions, including how best to present prognostic information to patients; methods for training clinicians and others to assist patients in this process; and systems for assuring that directives are available and up-to-date.

Discrepancies in End-of-life Decisions Between Elderly Patients and Their Named Surrogates

Introduction: This study aims to determine the attitudes of Asian elderly patients towards invasive life support measures, the degree of patient-surrogate concordance in end-of-life decision making, the extent to which patients desire autonomy over end-of-life medical decisions, the reasons behind patients’ and surrogates’ decisions, and the main factors influencing patients’ and surrogates’ decision-making processes. We hypothesize that there is significant patient-surrogate discordance in end-of-life decision making in our community. Materials and Methods: The patient and surrogate were presented with a hypothetical scenario in which the patient experienced gradual functional decline in the community before being admitted for life-threatening pneumonia. It was explained that the outcome was likely to be poor even with intensive care and each patient-surrogate pair was subsequently interviewed separately on their opinions of extraordinary life support using a standardised questionnaire. Both parties were blinded to each other’s replies. Results: In total, 30 patients and their surrogate decision-makers were interviewed. Twenty-eight (93.3%) patients and 20 (66.7%) surrogates rejected intensive care. Patient-surrogate concurrence was found in 20 pairs (66.7%). Twenty-four (80.0%) patients desired autonomy over their decision. The patients’ and surrogates’ top reasons for rejecting intensive treatment were treatment-related discomfort, poor prognosis and financial cost. Surrogates’ top reasons for selecting intensive treatment were the hope of recovery, the need to complete final tasks and the sanctity of life. Conclusion: The majority of patients desire autonomy over critical care issues. Relying on the surrogates’ decisions to initiate treatment may result in treatment against patients’ wishes in up to one-third of critically ill elderly patients. Key words: Advanced medical directive, Intensive care