Elsevier

Journal of Critical Care

Volume 51, June 2019, Pages 39-45
Journal of Critical Care

Selecting and evaluating decision-making strategies in the intensive care unit: A systematic review

https://doi.org/10.1016/j.jcrc.2019.01.029Get rights and content

Highlights

  • Decision-making on treatment intensity, mostly benefits from enhanced communication

  • Frequent family meetings with predefined, transparent topics aids decision-making

  • Length of stay can be reduced for patients with a poor prognosis

  • ICU decision-making studies should address multiple outcome measures

Abstract

Purpose

Many patients in the Intensive Care Unit (ICU) die after a decision to withhold or withdraw treatment. To ensure that for each patient the appropriate decision is taken, a careful decision-making process is required. This review identifies strategies that can be used to optimize the decision-making process for continuing versus limiting life sustaining treatment of ICU patients.

Methods

We conducted a systematic review of the literature by searching PUBMED and EMBASE.

Results

Thirty-two studies were included, with five categories of decision-making strategies (1) integrated communication, (2) consultative communication, (3) ethics consultation, (4) palliative care consultation and (5) decision aids. Many different outcome measures were used and none of them covered all aspects of decisions on continuing versus limiting life sustaining treatment. Integrated communication strategies had a positive effect on multiple outcome measures. Frequent, predefined family-meetings as well as triggered and integrated ethical or palliative consultation were able to reduce length of stay of patients who eventually died, without increasing overall mortality.

Conclusions

The decision-making process in the ICU can be enhanced by frequent family-meetings with predefined topics. Ethical and palliative support is useful in specific situations. These interventions can reduce non-beneficial ICU treatment days.

Introduction

Physicians working in an Intensive Care Unit (ICU) are responsible for appropriate and proportional care for their patients. They evaluate the course of the disease, the effect of their treatment, and the prognosis of the patients with their team in order to advice or decide on the intensity of ICU treatment. In approximately 10% of all ICU patients the decision to forgo life sustaining treatment is made [1]. In the majority of patients who die in an ICU, a decision to withhold or withdraw life-sustaining therapy preceded death [[2], [3], [4], [5]]. Previous studies, however, reported high variability in the proportion of ICU patients dying after some sort of limitation in life sustaining therapy [3]. These variations were observed between countries, within countries and even between physicians within the same ICU [5,6].

In order to ensure that for each patient the most appropriate decision about continuing or limiting ICU treatment is made, a careful and preferably shared decision-making process is required. Shared decision-making ensures patients, or their surrogates, and clinicians to make evidence based and personalized health care decisions [7].

This decision-making process is complex and hard to define for the ICU setting. It minimally involves a stepwise process of gathering and interpretation of information, weighing different options and ultimately a (shared-) decision [7]. There is limited evidence on the required steps of the decision making process on continuing or limiting ICU treatment and how each step contributes to a proportionate process and optimal decision [8]. It is unclear if decision making benefits most from particular steps in the process, or merely by standardizing the process.

Another factor that adds to the complexity of identifying optimal decision-making is defining the right outcome measure for studies on this topic. Patient-related outcomes, surrogate decision-maker outcomes, healthcare utilization and process measures are all important outcomes that apply to the various parties involved in decision-making in the ICU. Reducing subjectivity and variability could be desirable form the caregivers' point of view, while patients and families might define optimal decision-making by satisfaction with the communication or reduced non-beneficial treatment days [9]. Since all stakeholders have their own perspective, study endpoints vary accordingly, hampering a straightforward comparison on the different decision-making strategies.

Given the observed variability in the incidence of decisions on limiting life sustaining therapy, as well as their complexity and their impact on patients and families, there is a need for a better understanding of how to optimize this process. Although the decision-making process may be largely intuitive, including family meetings and consultation of other stakeholders, focussing on the individual steps of this process could benefit the process as a whole.

The aim of this systematic review was to identify which strategies can be used to optimize the decision-making process for continuing versus limiting life sustaining treatment of ICU patients and to describe usable outcome measures.

Section snippets

Study design

We conducted a systematic review of the literature after using the scoping review approach to define our research question. A scoping study is aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area or field. It is performed systematically and evidence is presented visually as a mapping or charting of the data [10,11]. We followed the approach as suggested for conducting a systematic scoping review by the Arksey and O'Malley framework enhanced by Levac

Search results

The initial database search (Fig. 1) yielded 9525 results (updated December 2018), from which 2487 duplicates were removed. From the 7038 unique studies, 6707 were excluded after title-abstract screening. 331 studies were selected for full-text evaluation. For 56 studies the full-text articles could not be obtained. A review of these titles and abstracts showed a variety of strategies that were not unique and mentioned in other studies selected for full-text review. Therefore, excluding these

Discussion

The aim of this systematic review was to identify strategies that can be used to optimize the decision-making process on continuing versus limiting life sustaining treatment of ICU patients and to map out strategies in relation to outcome measures.

We found 32 publications describing a strategy aimed at improving this decision-making process in adult ICU patients. Most publications had unclear or high risk of bias. Strategies could be grouped in five categories. Nine frequently used outcome

Conclusion

Enhancing the frequency and quality of communication between ICU caregivers and the patients' family with a standardized format improves the decision-making process for continuing versus limiting life sustaining treatment of ICU patients. Ethical and palliative support is useful in specific situations, when integrated in the standard ICU care. The multiple outcome measures that were found in this review illustrate the complexity of evaluating decision-making strategies in the ICU. Several

Declarations of interest

None.

Acknowledgments

This study was supported by the NutsOhra Foundation, project nr 1404-013.

References (56)

  • T.J. Prendergast et al.

    A national survey of end-of-life care for critically ill patients

    Am J Respir Crit Care Med

    (1998)
  • I.J. Higginson et al.

    Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, the Psychosocial Assessment and Communication Evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty

    BMC Med

    (2013)
  • N.M. Mark et al.

    Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review

    Intensive Care Med

    (2015)
  • A.E. Barnato et al.

    Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity

    Intensive Care Med

    (2012)
  • A.A. Kon et al.

    Shared decision-making in intensive care units. Executive summary of the American college of critical care medicine and American thoracic society policy statement

    Am J Respir Crit Care Med

    (2016)
  • L.P. Scheunemann et al.

    How clinicians discuss critically ill patients' preferences and values with surrogates: an empirical analysis

    Crit Care Med

    (2015)
  • D.J.C. Wilkinson et al.

    The luck of the draw: physician-related variability in end-of-life decision-making in intensive care

    Intensive Care Med

    (2013)
  • M.D.J. Peters et al.

    Guidance for conducting systematic scoping reviews

    Int J Evid Based Healthc

    (2015)
  • H. Arksey et al.

    Scoping studies: towards a methodological framework

    Int J Soc Res Methodol

    (2007)
  • D. Levac et al.

    Scoping studies: advancing the methodology

    Implement Sci

    (2010)
  • Covidence systematic review software, Veritas Health Innovation; Melbourne, Australia, (Available at)...
  • J.M. Teno et al.

    Do advance directives provide instructions that direct care? SUPPORT investigators. Study to understand prognoses and preferences for outcomes and risks of treatment

    J Am Geriatr Soc

    (1997)
  • D.B. White et al.

    A randomized trial of a family-support intervention in intensive care units

    N Engl J Med

    (2018)
  • C.M. Lilly et al.

    Intensive communication: four-year follow-up from a clinical practice study

    Crit Care Med

    (2003)
  • C.E. Cox et al.

    Development and pilot testing of a decision aid for surrogates of patients with prolonged mechanical ventilation

    Crit Care Med

    (2012)
  • J. Teno et al.

    Advance directives for seriously Ill hospitalized patients: effectiveness with the patient self-determination act and the support intervention

    J Am Geriatr Soc

    (1997)
  • J.P.T. Higgins et al.

    The cochrane collaboration's tool for assessing risk of bias in randomised trials

    BMJ

    (2011)
  • S.A. Norton et al.

    Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients

    Crit Care Med

    (2007)
  • Cited by (17)

    • Family-clinician shared decision making in intensive care units: Cluster randomized trial in China

      2022, Patient Education and Counseling
      Citation Excerpt :

      In recent years, studies have been conducted in the ICU populations to improve patient-centered care, family-clinician communication, and reducing family distress with various interventions [20–22]. However, literature review unveiled that there were limited original RCT studies focusing on the intervention of SDM in ICU settings [22]. This indicates an important gap in our understanding.

    • Ethical content of expert recommendations for end-of-life decision-making in intensive care units: A systematic review

      2020, Journal of Critical Care
      Citation Excerpt :

      A study conducted by Schneiderman et al. has shown that ethics consultations in ICU lead to significant reduction in nonbeneficial treatments, and it was agreed by both medical professionals, patients and surrogate decision makers that ethics consultations are helpful in addressing treatment conflicts [42]. It has been shown that both ethics and palliative care consultations lead to a reduced length of stay in the ICU, and even a reduced number of ICU admissions for patients at high risk of death if the palliative care consultations occurred upon hospitalization [43,44]. Palliative care experts try to improve the quality of dying and death (including ethical and legal aspects of decision making, the goal-setting with families experiencing high levels of distress or conflicts among members), all the while reducing the burden for caregivers, and possessing the required experience, knowledge and understanding [45].

    View all citing articles on Scopus
    View full text