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Kelly D, Barrett J, Brand G, Leech M, Rees C. Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review. Aust Crit Care 2024:S1036-7314(24)00049-3. [PMID: 38609749 DOI: 10.1016/j.aucc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. AIM The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. DESIGN Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. METHODS Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. RESULTS Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. CONCLUSION Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.
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Affiliation(s)
- Diane Kelly
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia.
| | - Jonathan Barrett
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia
| | - Gabrielle Brand
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Frankston, VIC, Australia
| | - Michelle Leech
- Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Charlotte Rees
- Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; School of Health Sciences, College of Medicine, Nursing & Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
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Warner BE, Lound A, Grailey K, Vindrola-Padros C, Wells M, Brett SJ. Perspectives of healthcare professionals and older patients on shared decision-making for treatment escalation planning in the acute hospital setting: a systematic review and qualitative thematic synthesis. EClinicalMedicine 2023; 62:102144. [PMID: 37588625 PMCID: PMC10425683 DOI: 10.1016/j.eclinm.2023.102144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023] Open
Abstract
Background Shared Decision-Making (SDM) between patients and clinicians is increasingly considered important. Treament Escalation Plans (TEP) are individualised documents outlining life-saving interventions to be considered in the event of clinical deterioration. SDM can inform subjective goals of care in TEP but it remains unclear how much it is considered beneficial by patients and clinicians. We aimed to synthesise the existing knowledge of clinician and older patient (generally aged ≥65 years) perspectives on patient involvement in TEP in the acute setting. Methods Systematic database search was performed in MEDLINE, EMBASE, PsycInfo and CINAHL databases as well as grey literature from database inception to June 8, 2023, using the Sample (older patients, clinicians, acute setting; studies relating to patients whose main diagnosis was cancer or single organ failure were excluded as these conditions may have specific TEP considerations), Phenomenon of Interest (Treatment Escalation Planning), Design (any including interview, observational, survey), Evaluation (Shared Decision-Making), Research type (qualitative, quantitative, mixed methods) tool. Primary data (published participant quotations, field notes, survey results) and descriptive author comments were extracted and qualitative thematic synthesis was performed to generate analytic themes. Quality assessment was made using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess overall confidence in each thematic finding according to methodology, coherence, adequacy and relevance of the contributing studies. The study protocol was registered on PROSPERO, CRD42022361593. Findings Following duplicate exclusion there were 1916 studies screened and ultimately 13 studies were included, all from European and North American settings. Clinician-orientated themes were: treatment escalation is a medical decision (high confidence); clinicians want the best for their patients amidst uncertainty (high confidence); involving patients and families in decisions is not always meaningful and can involve conflict (high confidence); treatment escalation planning exists within the clinical environment, organisation and society (moderate confidence). Patient-orientated themes were: patients' relationships with Treatment Escalation Planning are complex (low confidence); interactions with doctors are important but communication is not always easy (moderate confidence); patients are highly aware of their families when considering TEP (moderate confidence). Interpretation Based on current evidence, TEP decisions appear dominated by clinicians' perspectives, motivated by achieving the best for patients and challenged by complex decisions, communication and environmental factors; older patients' perspectives have seldom been explored, but their input on decisions may be modest. Presenting the context and challenge of SDM during professional education may allow reflection and a more nuanced approach. Future research should seek to understand what approach to TEP decision-making patients and clinicians consider to be optimum in the acute setting so that a mutually acceptable standard can be defined in policy. Funding HCA International and the NIHR Imperial Biomedical Research Centre.
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Affiliation(s)
- Bronwen E. Warner
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
| | - Adam Lound
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
| | - Kate Grailey
- Centre for Health Policy, Institute for Global Health Innovation, Department of Surgery and Cancer, Imperial College London, UK
| | | | - Mary Wells
- Department of Surgery and Cancer, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Stephen J. Brett
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
- Department of Intensive Care Medicine, Imperial College Healthcare NHS Trust London, London, UK
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Kennedy AC, Jones DA, Eastwood GM, Wellington D, See E, Lewis JE. Improving the quality of family meeting documentation in the ICU at the end of life. Palliat Care Soc Pract 2022; 16:26323524221128838. [PMID: 36268273 PMCID: PMC9577088 DOI: 10.1177/26323524221128838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 09/06/2022] [Indexed: 11/11/2022] Open
Abstract
Objective Improve documentation quality of end-of-life family meetings in a tertiary intensive care unit (ICU). Design Before-and-after interventional quality improvement project between October 2018 and February 2020 utilising an electronic pro-forma record. Setting Australian, University affiliated, mixed medical-surgical 22 bed adult ICU. Participants Patients who were admitted to the ICU for active management and subsequently died during that ICU admission. We enrolled 50 patients who died before and 50 patients after the introduction of the electronic family meeting pro-forma record. Intervention Through collaboration with ICU medical and nursing staff, End-of-life Special Interest Group and Clinical Documentation Committee we developed the ICU Family Meeting Discussion Note as an electronic pro-forma record with multiple key fields of entry. Main outcome measures Patient records were examined for the presence of documented details around patient's admission, family meetings and specific elements surrounding the patient's death. Results The introduction of a pro-forma record markedly improved the quality of documentation of end-of-life care related family meetings. Documentation increased in recording hospital admission date/time (6% vs 84%), meeting location (14% vs 70%), the reason patients were absent from the meeting (34% vs 72%), the Medical Treatment Decision Maker (MTDM) (10% vs 44%), the patient's resuscitation status (22% vs 54%), and treatment options discussed (78% vs 94%) (p ⩽ 0.005 for all). Conclusion Introducing an electronic pro-forma record to facilitate family meeting documentation increased the frequency of important recorded information. Further studies are required to assess whether documentation quality improvements are sustainable and whether they affect patient- or relative-centred outcomes.
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Affiliation(s)
| | - Daryl A. Jones
- Intensive Care Unit, Austin Hospital,
Heidelberg, VIC, Australia
| | | | | | - Emily See
- Intensive Care Unit, Austin Hospital,
Heidelberg, VIC, Australia
| | - Jane E. Lewis
- Intensive Care Unit, Austin Hospital, c/o ICU,
145 Studley Rd, Heidelberg, VIC 3084, Australia
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Mallidou AA, Tschanz C, Antifeau E, Lee KY, Mtambo JK, Heckl H. The Medical Orders for Scope of Treatment (MOST) form completion: a retrospective study. BMC Health Serv Res 2022; 22:1186. [PMID: 36131303 PMCID: PMC9492459 DOI: 10.1186/s12913-022-08542-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Advance care planning (ACP) involves discussions about patient and families’ wishes and preferences for future healthcare respecting autonomy, improving quality of care, and reducing overtreatment. The Medical Orders for Scope of Treatment (MOST) form records person preferred level and types of treatment and intervention. Purpose To examine the MOST form use in inpatient units within a British Columbia (Canada) hospital, estimate and compare its completion rate, and inform health policies for continuous, quality and individualized patient care. Methods About 5,000 patients admitted to the participating tertiary acute care hospital during October 2020. Data from 780 eligible participants in medical, surgical, or psychiatry unit were analyzed with descriptive statistics, the chi-square test for group comparisons, and logistic regression to assess predictors of the MOST form completion. Results Participants’ (54% men) age ranged from 20–97 years (mean = 59.53, SD = 19.54). Mainly physicians (99.1%) completed the MOST form for about 60% of them. A statistically significant difference of MOST completion found among the units [Pearson χ2(df=2, n=780) = 79.53, p < .001, φ = .319]. Multivariate logistic regression analysis demonstrated that age (OR = 1.05, 95% CI 1.04 to 1.06) and unit admission (OR = .60, 95% CI 0.36 to 0.99 in psychiatry; and OR = .21, 95% CI 0.14 to 0.31 in surgery) were independently associated with the MOST form completion. Conclusion Our findings demonstrate a need for consistent and broad completion of the MOST form across all jurisdictions using, desirably, advanced electronic systems. Healthcare providers need to raise awareness of the MOST completion benefits and be prepared to discuss topics relevant to end-of-life. Further research is required on the MOST form completion.
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Affiliation(s)
- Anastasia A Mallidou
- School of Nursing, University of Victoria, B236 - HSD Building, 3800 Finnerty (Ring) Road, Victoria, BC, V8P 5C2, Canada.
| | - Coby Tschanz
- School of Nursing, University of Victoria, B236 - HSD Building, 3800 Finnerty (Ring) Road, Victoria, BC, V8P 5C2, Canada
| | - Elisabeth Antifeau
- Palliative Care and End of Life Services, Interior Health, Vancouver, VIC, Canada
| | | | | | - Holly Heckl
- School of Nursing, University of Victoria, B236 - HSD Building, 3800 Finnerty (Ring) Road, Victoria, BC, V8P 5C2, Canada
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Lagrotteria A, Swinton M, Simon J, King S, Boryski G, Ma IWY, Dunne F, Singh J, Bernacki RE, You JJ. Clinicians' Perspectives After Implementation of the Serious Illness Care Program: A Qualitative Study. JAMA Netw Open 2021; 4:e2121517. [PMID: 34406399 PMCID: PMC8374609 DOI: 10.1001/jamanetworkopen.2021.21517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient's resuscitation preferences (ie, code status), risking provision of care that is inconsistent with patients' values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations. OBJECTIVE To explore clinicians' experiences with the SICP 1 year after implementation. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted at 2 tertiary care hospitals in Canada. The SICP was implemented at Hamilton General Hospital (Hamilton, Ontario) from March 1, 2017, to January 19, 2018, and at Foothills Medical Centre (Calgary, Alberta) from March 1, 2018, to December 31, 2020. A total of 45 clinicians were invited to participate in the study, and 23 clinicians (51.1%) were enrolled and interviewed. Semistructured interviews of clinicians were conducted between August 2018 and May 2019. Content analysis was used to evaluate information obtained from these interviews between May 2019 and May 2020. EXPOSURES The SICP includes clinician training, communication tools, and processes for system change. MAIN OUTCOMES AND MEASURES Clinicians' experiences with and perceptions of the SICP. RESULTS Among 23 clinicians interviewed, 15 (65.2%) were women. The mean (SD) number of years in practice was 14.6 (9.1) at the Hamilton site and 12.0 (6.9) at the Calgary site. Participants included 19 general internists, 3 nurse practitioners, and 1 social worker. The 3 main themes were the ways in which the SICP (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally. Changes in clinician behavior were supported by having a unit champion, interprofessional engagement, access to copies of the Serious Illness Conversation Guide, and documentation in the electronic medical record. Elements of the program, especially the Serious Illness Conversation Guide, shifted the focus of goals-of-care conversations beyond discussion of code status and influenced clinicians on personal and professional levels. Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity. CONCLUSIONS AND RELEVANCE In this qualitative study, hospital clinicians described components of the SICP as supporting changes in their behavior and facilitating meaningful patient interactions that shifted the focus of goals-of-care conversations beyond discussion of code status. The perceived benefits of SICP implementation stimulated uptake within the medical units. These findings suggest that the SICP may prompt hospital culture changes in goals-of-care dialogue with patients and the care of hospitalized patients with serious illness.
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Affiliation(s)
- Andrew Lagrotteria
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marilyn Swinton
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Simon
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Seema King
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Irene Wai Yan Ma
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Dunne
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Japteg Singh
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rachelle E. Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - John J. You
- Division of General Internal and Hospitalist Medicine, Department of Medicine, Trillium Health Partners, Credit Valley Hospital, Mississauga, Ontario, Canada
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Laan BJ, Huiszoon WB, Holleman F, Boermeester MA, Kaasjager KAH, Geerlings SE. Patient education materials to implement choosing wisely recommendations for internal medicine at the emergency department. BMJ Open Qual 2021; 10:bmjoq-2020-000971. [PMID: 33547155 PMCID: PMC7871247 DOI: 10.1136/bmjoq-2020-000971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Choosing Wisely aims to reduce low-value care to improve quality and lower costs. In the Netherlands, this campaign offers three recommendations for internal medicine applicable in emergency departments (EDs): (1) do not place an indwelling urinary catheter in non-critically ill patients who can void; (2) do not order plain abdominal radiographs in patients with acute abdominal pain; and (3) discuss whether treatment limitations are needed. This quality improvement project aims to increase the implementation of the recommendations by patient information leaflets. METHODS In a prospective before-after study, we collected data every other week during baseline and intervention periods (both 7 months) in two university medical centres. The primary outcomes were the adherence rates to the recommendations. RESULTS 805 patients visited the EDs for internal medicine, of whom 391 (48.6%) were hospitalised. Only 153 (19%) patients received the information leaflet. We found no change in implementation rates of the recommendations after the introduction of the patient information leaflet. In the baseline period, 28 patients received a urinary catheter, of whom 5 (17.9%) had no appropriate indication, compared with 4 (25.0%) of 16 patients in the intervention period (p=0.572). Unnecessary abdominal X-ray occurred once in the baseline period and not in the intervention period. Treatment limitations were not reported in 13 (6.5%) of 200 hospitalised patients in the baseline period, and in 17 (8.9%) of 191 patients in the intervention period (p=0.373). CONCLUSIONS Patient information leaflets did not increase the implementation of Choosing Wisely recommendations, which can be due to a high baseline rate and a poor dissemination of leaflets. Our ED seems not to be a practicable setting for dissemination of leaflets, since staff engagement was not possible due to high workload and shortage of qualified nursing staff in the Netherlands.
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Affiliation(s)
- Bart J Laan
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Willemijn B Huiszoon
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frits Holleman
- Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Karin A H Kaasjager
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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