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