ShareU.S. researchers examined how often clinicians and surrogates in intensive care units (ICUs) incorporate critically ill patients’ values and preferences into treatment decisions. They analysed 249 audiorecorded clinician-family conferences about prognosis and goals of care for incapacitated, critically ill patients.
Results show that most conferences lacked adequate communication, particularly in terms of deliberating about patients’ values and preferences and applying them to treatment decisions. Interventions are needed to better prepare surrogates for these difficult conversations and to improve clinicians’ communication skills, according to the study published in JAMA Internal Medicine.
The researchers performed a secondary analysis of a prospective, multicentre cohort study involving critically ill adults: 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Patient eligibility criteria included lack of decision-making capacity, a diagnosis of acute respiratory distress syndrome, and predicted in-hospital mortality of 50% or more. In addition to the patients, 451 surrogates and 144 clinicians at 13 ICUs at six U.S. academic and community medical centres were included.
Analysed transcripts of the audiorecorded clinician-family conversations revealed the following:
- Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%) contained no information exchange or deliberation about patients’ values and preferences.
- Clinicians and surrogates exchanged information about patients’ values and preferences in 167 (68.4%) of the conferences and specifically deliberated about how the patients’ values applied to the decision in 108 (44.3%).
- Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 87 (35.7%) or less of the conferences; surrogates provided a substituted judgement in 33 (13.5%); and clinicians made treatment recommendations based on patients’ values and preferences in 20 conferences (8.2%).
These findings expand on previous research showing that a significant proportion of clinician-family conferences about life support decisions lack adequate communication about incapacitated, critically ill patients’ values and preferences. While prior research has focused on the presence or absence of discussion about patients’ values and preferences, the current study delved deeper into the structure and content of those discussions.
The biggest gaps noted in this study occurred in deliberating how patients would feel facing the current situation, particularly regarding their expected level of functioning if they survive critical illness. Without a shared understanding of patients’ values and preferences in these areas, clinicians and families are likely to struggle to agree on a patient-centred treatment strategy.
Overall, the findings highlight the importance of developing interventions to better prepare surrogates to represent patients’ values and preferences in ICU family conferences and train clinicians to facilitate these conversations. Engaging surrogates in robust deliberation that connects patients’ end-of-life values with a treatment plan may help clinicians feel more comfortable that surrogates understand the quality-of-life implications of their decisions.
For now, the study authors recommend that clinicians should ask questions and recommend treatment based on their best understanding of how patients would feel about their expected lifestyle and functioning after critical illness.
Source: JAMA Internal Medicine
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