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Original Investigation
April 1, 2019

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

Author Affiliations
  • 1Division of Geriatric Medicine and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 2Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 3Department of Health Policy and Management, University of North Carolina at Chapel Hill
  • 4Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 5Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill
  • 6Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
  • 7Cambia Palliative Care Center of Excellence, University of Washington, Seattle
  • 8Palliative Care Program, University of California, San Francisco Medical Center, San Francisco
  • 9Division of Hospital Medicine, University of California, San Francisco School of Medicine, San Francisco
  • 10Department of Physiological Nursing, University of California, San Francisco School of Nursing, San Francisco
  • 11Division of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School–Baystate, Springfield
  • 12The Greenwall Foundation, New York, New York
  • 13Departments of Medicine and Anesthesia and Perioperative Care, University of California, San Francisco
  • 14Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 15Palliative and Supportive Institute, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania
JAMA Intern Med. 2019;179(5):676-684. doi:10.1001/jamainternmed.2019.0027
Key Points

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

Findings  In this secondary analysis of a cohort study, 249 clinician-family intensive care unit conferences were analyzed for statements that exchanged information about incapacitated patients’ treatment preferences and health-related values and applied them to deliberation and treatment planning. Most conferences lacked adequate communication, particularly in terms of deliberating about patients’ values and preferences and applying them to treatment decisions.

Meaning  Interventions are needed to better prepare surrogates for these difficult conversations and to improve clinicians’ communication skills.

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 audiorecorded 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.

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