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May - 2019

   

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Clinician-Family Communication About Patients’ Values and Preferences in Intensive Care Units

LP. Scheunemann, NC. Ernecoff, P Buddadhumaruk, et al JAMA Int Med, 2019, online first April 2019

Comment

Shared decision-making is becoming a concept that out patients, families, society want us to understand and engage in. There are 3 components to shared decision-making;

1) information exchange about both clinical issues (ie, diagnosis, prognosis, and treatment options) and personal issues (ie, patients’ values and preferences)

(2) deliberation about how to apply patients’ values to the clinical situation

(3) development of a treatment plan that respects patients’ preferences. 

 

A key component of this is the identification and discussion of patients’ values (ie, what is important to them) and preferences (ie,what treatment they want). When we get this right, we achieve shared decision-making. When we deliver care aligned to patients values we achieve goal-concordant care. 

 

To what extent do clinicians and surrogates in intensive care units incorporate critically ill patients’ values and preferences into treatment decisions?

 

This secondary analysis of a prospective, multicenter cohort study of audiorecorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults with predicted ROD >50%,  has helped answer this question. 

Conferences were analysed for statements that exchanged information about incapacitated patients’ treatment preferences and health-related values and applied them to deliberation and treatment planning. A quantitative coding scheme following Crabtree and Miller’s template method and a published framework for discussing incapacitated patients’ values and preference with surrogate decision makers was used. They coded for maximal inclusiveness, and broadly defined values as patient’s lifestyle, activities, attitudes, beliefs, and feelings about what makes life worth living, including prior vocation, family ties, substance use, hobbies, functional status, and personality traits. Preferences refer to a patient’s previously stated wishes about life-extending treatments (ie, oral or written advance directives).

They report;

  • Most conferences lacked adequate communication, particularly in terms of deliberating about patients’ values and preferences and applying them to treatment decisions.
  • 249 patients had an audio recorded conversation, involving 450 surrogates and 141 clinicians. 244 included a decision about goals of care
  • 26% of conversations contained neither information exchange or deliberation about patients’ values and preferences. 
  • 68% of conversations included clinicians and surrogate exchange of information about patients’ values and preferences
  • 44% of conversations included specific deliberation of how patients’ values applied to the decision
  • Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed < 1.3 of conversations
  • Surrogates provided a substituted judgment in 14%
  • Clinicians made treatment recommendations based on patients’ values and preferences in 8% of conversations

These percentages describe a pattern of conversations where shared decision-making is not the norm. This is either due to lack of identification of patients values and preferences or lack of deliberation of how these apply to treatment decisions. As a result only 1:12 meetings resulted in clinicians explicitly basing a treatment recommendation on patients values and preferences. 

There are more nuanced lessons. Structurally values are discussed more frequently than consideration of how to apply them to the current patient circumstances, suggesting areas to focus son to improve person-centred care. The authors recommend;

  1. interventions should be developed to better prepare surrogates for these difficult conversations—a major focus of advance care planning research.
  2. interventions are needed to teach clinicians communication skills for eliciting patients’ values and preferences and then incorporating them into a treatment plan.
  3. increased awareness that patients’ values and preferences tend to be a blind spot in these conversations may prompt clinicians to discuss them

 

Abstract

Importance  Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating intensive care unit (ICU) patients’ values and preferences into treatment decisions.

Objectives  To determine how often clinicians and surrogates exchange information about patients’ previously expressed values and preferences and deliberate and plan treatment based on these factors during conferences about prognosis and goals of care for incapacitated ICU patients.

Design, Setting, and Participants  A secondary analysis of a prospective, multicenter cohort study of audio recorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults was conducted. The study was performed between October 8, 2009, and October 23, 2012. Data analysis was performed between July 2, 2014, and April 20, 2015. 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 6 US academic and community medical centers were included.

Main Outcomes and Measures  Two coders analyzed transcripts of audiorecorded conversations for statements in which clinicians and surrogates exchanged information about patients’ treatment preferences and health-related values and applied them in deliberation and treatment planning.

Results  Of the 249 patients, 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%; 95% CI, 20.3%-31.3%) 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%) (95% CI, 62.6%-74.3%) of the conferences and specifically deliberated about how the patients’ values applied to the decision in 108 (44.3%; 95% CI, 38.0%-50.5%). 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 judgment in 33 (13.5%); and clinicians made treatment recommendations based on patients’ values and preferences in 20 conferences (8.2%).

Conclusions and Relevance  Most clinician-family conferences about prognosis and goals of care for critically ill patients appear to lack important elements of communication about values and preferences, with robust deliberation being particularly deficient. Interventions may be needed to better prepare surrogates for these conversations and improve clinicians’ communication skills for eliciting and incorporating patients’ values and preferences into treatment decisions.

May


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