Selecting and Evaluating Decision-Making Strategies in the Intensive Care Unit: A Systematic Review

Kerckhoffs M, Kant M, Van Delde J et al.

Journal of Critical Care (2019): 51; 39-45. https://doi.org/10.1016/j.jcrc.2019.01.029

Aim of Study

Decisions on ITU are complex – physicians need to be able to evaluate the course of disease, the effect that treatment will have and prognosis. There should be a shared decision-making process which is individualised but based on evidence. The aim of this review was to try and understand the process of decision making and try to find best ways to optimise it

Design and Location

Systematic review and scoping study, majority of those used were from the US (28 out of 32).

Methodology

9525 initial studies were identified – 32 met the criteria and were used for this review.  All studies were screened by two independent reviewers.

The article described a strategy aimed at process of decision-making on continuing or limiting life sustaining treatment on ITU. It should include:

1. Information on communication with patients/surrogates.
2. Information on patients prognosis and treatment preferences gathered.
3. Decision on goals of ITU care.

Strategies Studied

1. Integrating communication in standard ITU care
2. Offering consultative communicative support
3. Ethics consultation
4. Consulting and integrating palliative care
5. Decision aids

Results

1. Integrating communication in standard ITU care

13 studies looked at communication strategies and 7 used defined topics to discuss.

All showed beneficial effects on: time to decision making, number of family discussions and documentation of goals. The other most common effect was reducing length of ITU stay (reduced in 5, no different in 1). Two studies 2 looked at family attendance during ITU ward round, they found an increase in knowledge and reduction in need for other family discussions and nurse’s workload. One study also looked at psychological stress in surrogates which was not found to be reduced.

2. Offering consultative communicative support

Four studies looked at communication strategies delivered by non ITU healthcare professionals and found no distinct effect and conflicting results.

3. Ethics consultation

Four studies look at the addition of ethics consultations and they found that there was a reduced length of stay.

4. Consulting and integrating palliative care

Six studies looked at this using either an integrated or consultative method and they found that length of stay was reduced in 4 out of 6 studies. Three looked at effects on surrogates and these found that palliative care failed to improve either perceived quality of dying, satisfaction with care or depressive/anxiety associated symptoms.

5. Decision aids

Four studies used decisions aids which either related to intensity of care or CPR. This included a 3-minute video which was shown to patients and surrogates regarding CPR. One study included a giving surrogates a personalised decision aid. Two of the studies found that in those patients, there was a reduction in length of stay which then caused a reduction in costs associated with admission. There was also a reduction in time to first consideration of level of appropriate treatments.

Conclusions/Discussions

Enhancing communication was shown to reduce non-beneficial treatment days and simple interventions such as good communication had an important impact .

Improving discussions:

• Standardised format (but personalised) with structure and topics – can act as decision aid
• Increase frequency of family meetings – leads to more timely decisions
• Integrated into ITU care (including WR)

Palliative care is a useful tool in some cases on ITU if integrated into care. Family satisfaction did not improve, likely due to the high level of satisfaction already present – could use more specific questionnaires. Several studies showed a reduced length of stay in those who eventually died, and this also reduced the number of non-beneficial treatment days and caused more timely decisions in patients with a poor prognosis.

Stated Limitations from the Study

• Bias
• Majority of studies done in US
• Some studies were in an experimental setting
• Decision making practices vary
• Complicated practice to capture with multiple outcomes and end points.

Discussion from Journal Club Meeting (?Change of Practice)

We already provide good communication on the unit. Consultant led discussions happen regularly. The main discuss point was around admitting the right patients to ITU and therefore avoiding a long and sometimes distressing admission to patients whose outcome was always going to be poor. Additionally, this relates to the type of patients who are being taken for significant surgery with high mortality rates. Is this in their best interests?

We felt that showing patients and families videos about CPR would not be in their best interests while a patient is very unwell. What would be useful would be an honest discussion about resuscitation and making Advanced Care Plans in the community. GPs could lead this and potentially prevent inappropriate resuscitation and admissions to ITU.

Summary by Dr H Holyoak. Journal Club Meeting 21 February 2019.