Interventions for Shared Decision-Making About Life Support in the Intensive Care Unit: A Systematic Review

The effects of shared decision making on health outcomes, health care quality, cost, and consultation time: An umbrella review

OBJECTIVE

To review the effects of shared decision making (SDM) on health outcomes, health care quality, cost, and consultation time METHODS: We conducted an umbrella review and searched systematic reviews on SDM from PubMed, CINHAL, and Web of Science. We included reviews on SDM interventions used in a health care setting with patients. We assessed the eligibility of retrieved articles and evaluated whether the review addressed Consolidated Framework for Implementation Research (CFIR) characteristics.

RESULTS

Out of 3678 records, 48 reviews were included. Half of the reviews focused exclusively on RCT studies (n = 21). A little less than half were focused specifically on decision aids (n = 23). Thirty-two reviews discussed CFIR characteristics explicitly or implicitly; the majority of which were specific to intervention characteristics. Reviews tended to cluster around patient populations and tended to be low or critically low to moderate in their quality. Reviews of SDM on health outcomes, health care quality, cost, and consultation time were highly uncertain but often ranged from neutral to positive.

CONCLUSIONS

We observed that SDM implementation did not typically increase costs or increase consultation time while having some neutral to positive benefits on outcomes and quality for certain populations. Gaps in knowledge remain including better research on the climate where SDM is most effective.

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.

A Survey of Emergency Nurses' Perceptions and Practices to Support Patients' Families as Surrogate Decision Makers

INTRODUCTION

Family members acting as surrogate decision makers for severely ill patients in emergency and critical care centers face psychological burdens. This study aimed to investigate the actual situation of emergency nurses' perceptions and practices to support patients' families and its structural elements.

METHODS

We created an original 25-item questionnaire and surveyed 164 emergency nurses from 64 emergency and critical care centers regarding their perceptions of caring for people making surrogate decisions. Participants averaged 35.6 years old and 5.1 years as emergency nurses.

RESULTS

Cronbach's α coefficients for importance and practice on the original questionnaire were 0.936 and 0.933, respectively. We identified 4 elements of necessary support for patient families making surrogate decisions according to emergency nurses: "collaboration in understanding the condition of the patient as well as empathetic support," "care that addresses the needs of patient's family members," "confirming the role of nurses and surrogate decision making," and "participation in meeting with a doctor and patient families." In addition, we identified 5 elements that indicate the current state of practice: "support from specialists such as nurses and other professionals," "compassionate care for family members and those who are providing support to family members," "empathetic support for family members," "support for making arrangements that address the needs of family members," and "considerations for family members."

DISCUSSION

According to the findings of this study, emergency nurses should coordinate with other professionals and talk with family members and physicians to increase their understanding of the need to assist in surrogate decision making. In addition, emergency nurses also need to explain to patients' relatives how to support them in surrogate decision making.

Supporting families of patients who die in adult intensive care: A scoping review of interventions

BACKGROUND

Families who perceive themselves as prepared for an impending death experience reduced psychological burden during bereavement. Understanding which interventions promote death preparedness in families during end-of-life care in intensive care will inform future intervention development and may help limit the burden of psychological symptoms associated with bereavement.

AIM

To identify and characterise interventions that help prepare families for the possibility of death in intensive care, incorporating barriers to intervention implementation, outcome variables and instruments used.

DESIGN

Scoping review using Joanna Briggs methodology, prospectively registered and reported using relevant guidelines.

DATA SOURCES

A systematic search of six databases from 2007 to 2023 for randomised controlled trials evaluating interventions that prepared families of intensive care patients for the possibility of death. Citations were screened against the inclusion criteria and extracted by two reviewers independently.

RESULTS

Seven trials met eligibility criteria. Interventions were classified: decision support, psychoeducation, information provision. Psychoeducation involving physician-led family conference, emotional support and written information reduced symptoms of anxiety, depression, prolonged grief, and post-traumatic stress in families during bereavement. Anxiety, depression, and post-traumatic stress were assessed most frequently. Barriers and facilitators to intervention implementation were seldom reported.

CONCLUSION

This review provides a conceptual framework of interventions to prepare families for death in intensive care, while highlighting a gap in rigorously conducted empirical research in this area. Future research should focus on theoretically informed, family-clinician communication, and explore the benefits of integrating existing multidisciplinary palliative care guidelines to deliver family conference within intensive care.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care clinicians should consider innovative communication strategies to build family-clinician connectedness in remote pandemic conditions. To prepare families for an impending death, mnemonic guided physician-led family conference and printed information could be implemented to prepare families for death, dying and bereavement. Mnemonic guided emotional support during dying and family conference after death may also assist families seeking closure.

Do Interventions Improve Symptoms Among ICU Surrogates Facing End-of-Life Decisions? A Prognostically-Enriched Systematic Review and Meta-Analysis

OBJECTIVES

Evaluate the efficacy of interventions to improve symptoms for ICU surrogates at highest risk of developing psychologic distress: those facing end-of-life care decisions.

DATA SOURCES

MEDLINE, CINAHL, PsycInfo, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched through April 16, 2022.

STUDY SELECTION

Following an a priori protocol, randomized trials of interventions delivered to surrogates of adult ICU patients who died or had high likelihood of mortality evaluating surrogate symptoms were identified.

DATA EXTRACTION

Two reviewers performed screening and data extraction and assessed risk of bias (Cochrane Risk of Bias [RoB] 2 tool). Trials were eligible for meta-analysis if group mean symptom scores were provided at 3 or 6 months. Pooled effects were estimated using a random effects model. Heterogeneity was assessed (Cochrane Q, I2 ). Certainty of evidence was assessed (Grading of Recommendations Assessment, Development and Evaluation).

DATA SYNTHESIS

Of 1,660 records, 10 trials met inclusion criteria representing 3,824 surrogates; eight were included in the meta-analysis. Overall RoB was rated Some Concerns. Most ( n = 8) interventions focused on improving communication and enhancing psychologic support in the ICU. All trials measured anxiety, depression, and posttraumatic stress. Significant improvement was seen at 3 months (depression, mean difference [MD], -0.68; 95% CI, -1.14 to -0.22, moderate certainty; posttraumatic stress, standardized MD, -0.25; 95% CI, -0.49 to -0.01, very low certainty) and 6 months (anxiety, MD, -0.70; 95% CI, -1.18 to -0.22, moderate certainty). Sensitivity analyses suggest significant findings may be unstable. Subgroup analyses demonstrated differences in effect by trial location, interventionist, and intervention dose.

CONCLUSIONS

Communication and psychological support interventions in the ICU yielded small but significant improvement in psychological symptoms with moderate to very low certainty evidence in a prognostically-enriched sample of ICU surrogates facing end-of-life care decisions. A new approach to interventions that extend beyond the ICU may be needed.

Role Mismatch in Medical Decision-Making Participation Is Associated with Anxiety and Depression in Family Members of Patients in the Intensive Care Unit

This study aimed to investigate the mismatch between the preferred and actual roles in the medical decision-making of intensive care unit (ICU) patients' family members and the relationship between the role mismatch of family members' decisions and anxiety and depression syndromes. A total of 223 family members of ICU patients in the Affiliated Hospital of Jiangnan University in China were enrolled. The simple Chinese version of the Control Preference Scale was used to complete the surveys to assess the preferred and actual roles, and anxiety and depression syndromes were measured using the Generalized Anxiety Disorder-7 scale and Patient Health Questionnaire-9, respectively. For the preferred and actual roles, the active role rates were 16.1% and 8.1%, the cooperative role rates were 49.3% and 31.4%, and the passive role rates were 34.5% and 60.5%, respectively. The incidence of mismatch was 43.0% between the preferred and actual roles, and the consistency between their preferred and actual decision-making roles was poor (kappa = 0.309, P < 0.001). Family members with mismatched decision-making roles had significantly higher incidence rates of anxiety (90.6% vs. 57.5%, P < 0.001) and depression (86.5% vs. 63.0%, P < 0.001). Logistic regression analysis revealed that mismatches in decision-making roles remained independently associated with these outcomes after adjustment for family members' sociodemographic features. The results of the present study demonstrate that the preferred role of ICU patients' family members is mainly cooperative, and the actual role is mainly passive. The mismatch between the preferred and actual roles is associated with anxiety and depression among the ICU patients' family members.

Involvement of Jordanian Patients and Their Families in Decision Making Near End of Life, Challenges and Recommendations

This study aims to explore the challenges in involving patients and their families in decision making near end of life and to provide recommendations to overcome these challenges. A qualitative descriptive phenomenological approach was used with a purposive sample of 8 patients, 7 family caregivers, 7 nurses, and 6 physicians from 2 institutions that provide palliative and end-of-life care services in Jordan. Data were collected using interviews with patients and family caregivers and focus group discussions with nurses and physicians. Colaizzi's method was used to analyze the data. The thematic analysis revealed 5 themes representing the participants' experiences of challenges with decision making near end of life. The identified challenges are (1) struggle with lack of information; (2) improper communication; (3) patient's or family's decision: the cultural taboo; (4) health care providers prefer staying in their comfort zone; and (5) the paradox of surviving and letting go. In addition, the participants endorsed several recommendations to raise public awareness of palliative and end-of-life care, amplify the patients' voice, and raise the bar of communication sensitivity. Decision making near the end of life is a challenge. However, the current study highlighted several areas for improvement that can improve the process and optimize patients' and their families' involvement.

Development and implementation of a clinical information system-based protocol to improve nurse satisfaction of end-of-life care in a single intensive care unit

BACKGROUND

Patients treated in Australian intensive care units (ICUs) have an overall mortality rate of 5.05%. This is due to the critical nature of their disease, the increasing proportion of patients with multiple comorbidities, and advanced age. This has made treating patients during the end of life an integral part of intensive care practice and requires a high quality of care. With the increased use of electronic clinical information systems, a standardised protocol encompassing end-of-life care may provide an efficient method for documentation, communication, and timely delivery of comfort care.

OBJECTIVE

The aim of the study was to determine if an electronic clinical information system-based end-of-life care protocol improved nurses' satisfaction with the practice of end-of-life care for patients in the ICU.

DESIGN

This is a prospective single-centre observational study.

SETTING

The study was carried out at a 20-bed cardiothoracic and general ICU between 2015 and 2017.

PARTICIPANTS

The study participants were ICU nurses.

INTERVENTION

Electronic clinical information-based end-of-life care protocol was used in the study.

OUTCOME

The primary outcome was nurse satisfaction obtained by a survey.

RESULTS

The number of respondents for the before survey and after survey was 58 (29%) and 64 (32%), respectively. There was a significant difference between the before survey and the after survey with regard to feeling comfortable in transitioning from curative treatment (median = 2 [interquartile range {IQR} = 2, 3] vs 3 [IQR = 2, 3], p = 0.03), feeling involved in the decision to move from curative treatment to end-of-life care (median = 2 [IQR = 2, 2] vs 2 [IQR 2, 3], p = 0.049), and feeling religious beliefs/rituals should be respected during the end-of-life process (median = 4 [IQR = 3, 4] vs. 4 [IQR = 4, 4], p = 0.02). There were some practices that had a low satisfaction rate on both the before survey and after survey. However, a high proportion of nurses were satisfied with many of the end-of-life care practices.

CONCLUSION

The nurses were highly satisfied with many aspects of end-of-life care practices in this unit. The use of an electronic clinical information system-based protocol improved nurse satisfaction and perception of quality of end-of-life care practices for three survey questions.

A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition

CONTEXT

Palliative care continues to be a rapidly growing field aimed at improving quality of life for patients and their caregivers.

OBJECTIVES

The purpose of this review was to provide a synthesis of the evidence in palliative care to inform the fourth edition of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

METHODS

Ten key review questions addressing eight content domains guided a systematic review focused on palliative care interventions. We searched eight databases in February 2018 for systematic reviews published in English from 2013, after the last edition of National Consensus Project guidelines was published, to present. Experienced literature reviewers screened, abstracted, and appraised data per a detailed protocol registered in PROSPERO. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations criteria. The review was supported by a technical expert panel.

RESULTS

We identified 139 systematic reviews meeting inclusion criteria. Reviews addressed the structure and process of care (interdisciplinary team care, 13 reviews; care coordination, 18 reviews); physical aspects (48 reviews); psychological aspects (26 reviews); social aspects (two reviews); spiritual, religious, and existential aspects (11 reviews); cultural aspects (three reviews); care of the patient nearing the end of life (grief/bereavement programs, six reviews; final days of life, two reviews); ethical and legal aspects (36 reviews).

CONCLUSION

A substantial body of evidence exists to support clinical practice guidelines for quality palliative care, but the quality of evidence is limited.

Development of a decision aid for cardiopulmonary resuscitation and invasive mechanical ventilation in the intensive care unit employing user-centered design and a wiki platform for rapid prototyping

BACKGROUND

Upon admission to an intensive care unit (ICU), all patients should discuss their goals of care and express their wishes concerning life-sustaining interventions (e.g., cardiopulmonary resuscitation (CPR)). Without such discussions, interventions that prolong life at the cost of decreasing its quality may be used without appropriate guidance from patients.

OBJECTIVES

To adapt an existing decision aid about CPR to create a wiki-based decision aid individually adapted to each patient's risk factors; and to document the use of a wiki platform for this purpose.

METHODS

We conducted three weeks of ethnographic observation in our ICU to observe intensivists and patients discussing goals of care and to identify their needs regarding decision making. We interviewed intensivists individually. Then we conducted three rounds of rapid prototyping involving 15 patients and 11 health professionals. We recorded and analyzed all discussions, interviews and comments, and collected sociodemographic data. Using a wiki, a website that allows multiple users to contribute or edit content, we adapted the decision aid accordingly and added the Good Outcome Following Attempted Resuscitation (GO-FAR) prediction rule calculator.

RESULTS

We added discussion of invasive mechanical ventilation. The final decision aid comprises values clarification, risks and benefits of CPR and invasive mechanical ventilation, statistics about CPR, and a synthesis section. We added the GO-FAR prediction calculator as an online adjunct to the decision aid. Although three rounds of rapid prototyping simplified the information in the decision aid, 60% (n = 3/5) of the patients involved in the last cycle still did not understand its purpose.

CONCLUSIONS

Wikis and user-centered design can be used to adapt decision aids to users' needs and local contexts. Our wiki platform allows other centers to adapt our tools, reducing duplication and accelerating scale-up. Physicians need training in shared decision making skills about goals of care and in using the decision aid. A video version of the decision aid could clarify its purpose.

Nurse Communication About Goals of Care

Conversations about goals of care with the patient and family are a critical component of advanced practice in oncology. However, there are often inadequate team structures, training, or resources available to assist advanced practitioners in initiating these conversations. We conducted a study to assess nurses’ perceived role and communication tasks in such conversations about goals of care. In a cross-sectional survey of 109 nurses attending a comprehensive 2-day end-of-life nursing education course, nurses were asked to describe how they would participate in a "goals of care" meeting in three different scenarios. They were also asked what changes they desired in their clinical settings. Nurses overwhelmingly described that their primary task and communication role was to assess patient/family understanding. Nurses referenced their team members and team support with the least frequency across scenarios. Team roles, structure, and process were reported as areas in greatest need of change in patient/family goals of care meetings. These findings demonstrate that lack of preparation to function as a team is a barrier for nurses in communicating about goals of care, and there is a demand to move such conversations upstream in oncology care.

Development of a Decision Aid for Cardiopulmonary Resuscitation Involving Intensive Care Unit Patients' and Health Professionals' Participation Using User-Centered Design and a Wiki Platform for Rapid Prototyping: A Research Protocol

Background

Cardiopulmonary resuscitation (CPR) is an intervention used in cases of cardiac arrest to revive patients whose heart has stopped. Because cardiac arrest can have potentially devastating outcomes such as severe neurological deficits even if CPR is performed, patients must be involved in determining in advance if they want CPR in the case of an unexpected arrest. Shared decision making (SDM) facilitates discussions about goals of care regarding CPR in intensive care units (ICUs). Patient decision aids (DAs) are proven to support the implementation of SDM. Many patient DAs about CPR exist, but they are not universally implemented in ICUs in part due to lack of context and cultural adaptation. Adaptation to local context is an important phase of implementing any type of knowledge tool such as patient DAs. User-centered design supported by a wiki platform to perform rapid prototyping has previously been successful in creating knowledge tools adapted to the needs of patients and health professionals (eg, asthma action plans). This project aims to explore how user-centered design and a wiki platform can support the adaptation of an existing DA for CPR to the local context.

Objective

The primary objective is to use an existing DA about CPR to create a wiki-based DA that is adapted to the context of a single ICU and tailorable to individual patient’s risk factors while employing user-centered design. The secondary objective is to document the use of a wiki platform for the adaptation of patient DAs.

Methods

This study will be conducted in a mixed surgical and medical ICU at Hôtel-Dieu de Lévis, Quebec, Canada. We plan to involve all 5 intensivists and recruit at least 20 alert and oriented patients admitted to the ICU and their family members if available. In the first phase of this study, we will observe 3 weeks of daily interactions between patients, families, intensivists, and other allied health professionals. We will specifically observe 5 dyads of attending intensivists and alert and oriented patients discussing goals of care concerning CPR to understand how a patient DA could support this decision. We will also conduct individual interviews with the 5 intensivists to identify their needs concerning the implementation of a DA. In the second phase of the study, we will build a first prototype based on the needs identified in Phase I. We will start by translating an existing DA entitled “Cardiopulmonary resuscitation: a decision aid for patients and their families.” We will then adapt this tool to the needs we identified in Phase I and archive this first prototype in a wiki. Building on the wiki’s programming architecture, we intend to integrate the Good Outcome Following Attempted Resuscitation risk calculator into our DA to determine personal risks and benefits of CPR for each patient. We will then present the first prototype to 5 new patient-intensivist dyads. Feedback about content and visual presentation will be collected from the intensivists through short interviews while longer interviews will be conducted with patients and their family members to inform the visual design and content of the next prototype. After each rapid prototyping cycle, 2 researchers will perform qualitative content analysis of data collected through interviews and direct observations. We will attempt to solve all content and visual design issues identified before moving to the next round of prototyping. In all, we will conduct 3 prototyping cycles with a total of 15 patient-intensivist dyads.

Results

We expect to develop a multimedia wiki-based DA to support goals of care discussions about CPR adapted to the local needs of patients, their family members, and intensivists and tailorable to individual patient risk factors. The final version of the DA as well as the development process will be housed in an open-access wiki and free to be adapted and used in other contexts.

Conclusions

This study will shed new light on the development of DAs adapted to local context and tailorable to individual patient risk factors employing user-centered design and a wiki to support rapid prototyping of content and visual design issues.

Communication nonaccommodation in family conversations about end-of-life health decisions

Furthering our understanding of how communication can improve end-of-life decision making requires a shift in focus from whether people talk to how people talk about end-of-life health decisions. This study used communication accommodation theory to examine the extent to which communication nonaccommodation distinguished more from less successful end-of-life conversations among family members. We analyzed elicited conversations about end-of-life health decisions from 121 older parent/adult child dyads using outside ratings of communication over- and underaccommodation and self-reported conversational outcomes. Results of multilevel linear modeling revealed that outside ratings of underaccommodation predicted self-reported and partner-reported uncertainty, and ratings of overaccommodation predicted self-reported decision-making efficacy and change in concordance accuracy. We discuss the methodological, theoretical, and practical implications of these findings.

Managing futility in critically ill patients with cardiac disease

Despite extraordinary innovations in cardiology and critical care, cardiovascular disease remains the leading cause of death globally, and heart failure has one of the highest disease burdens of any medical condition in the Western world. The lethality of many cardiac conditions, for which symptoms and prognoses are worse than for many malignancies, is widely under-recognized. A number of strategies have been developed within specialties such as oncology to improve the care of patients with life-threatening conditions. For reasons that are multifactorial, these options are often denied to critically ill patients with cardiac disease. Cardiologists and intensivists often regard death as failure, continuing to pursue active treatment while potentially denying patients access to alternatives such as symptom control and end-of-life care. Patient autonomy is central to the delivery of high-quality care, demanding shared decision-making to ensure patient preferences are acknowledged and respected. Although many cardiologists and intensivists do provide thoughtful and patient-centred care, the pressure to intervene can lead to physician-centric care focused around the needs and wishes of medical staff to the detriment of patients, families, health-care workers, and society as a whole.