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

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.

Figure 1.. Main Coding Scheme and the Elements of Shared Decision Making

The left-hand side shows the process of shared decision making. During information exchange, clinicians share clinical facts (ie, diagnosis, prognosis, treatment options [yellow]) and surrogates share personhood information (ie, values and preferences [blue]). During deliberation, they discuss how to apply the information to the decisions at hand, blending clinical and personhood information (green). The goal of this process is a patient-centered treatment plan (green). The center shows the main coding scheme, which focuses on communication about the patient’s values and preferences (blue and green), as well as secondary codes to verify that value-laden treatments were discussed. The right-hand column describes the purpose of each code.

Figure 2.. Frequency of Information Exchange and Deliberation in Clinician–Family Conferences (n = 244)

Information exchange (A) and (B) deliberation about common end-of-life values. ADLs, activities of daily living; IADLs, instrumental ADLs.