Decision‐making among the substitute decision makers in intensive care units: An investigation of decision control preferences and decisional conflicts

Abstract

AimsTo explore decision control preferences and decisional conflicts and to analyse their association among the surrogate decision makers in the intensive care unit.DesignThe study carried out a cross‐sectional survey among the surrogates.MethodsThe participants were 115 surrogate decision makers of critical patients, from August to September 2019. A Chi‐squared test and logistic regression were used to assess decision control preferences and decisional conflicts, and Spearman's rank correlation coefficient was employed to examine their association.ResultsOf the 115 surrogate decision makers, 51.3% preferred a collaborative role, and 63.48% were somewhat unsure about making decisions. Logistic regression analysis identified decision control preferences was associated with surrogates’ age, education level, and personality traits, while decisional conflicts was associated with surrogates’ age, education level, character, medical expense burden, and Acute Physiology and Chronic Health Evaluation‐II score. Cohen's kappa statistics showed a bad concordance of decision‐making expectations and actuality, with kappa values of 0.158 (p < .05). Wherein surrogates who experienced discordance between their preferred and actual roles, have relatively higher decisional conflicts.ConclusionThis study identified individual differences of surrogate decision makers in decision control preferences and decisional conflicts. These results imply that incorporation of the individual decision preferences and communication styles into care plans is an important first step to develop high quality decision support.ImpactThis research is a contribution to the limited study on decision control preferences and decisional conflicts among surrogate decision makers of critically ill patients. Moreover based on the investigation of understanding the status and related factors of decision preferences and decisional conflicts set the stage for developing effective decision support interventions.

Prevalence of long-term decision regret and associated risk factors in a large cohort of ICU surrogate decision makers

“…Other measures of decision-making include decisional self-efficacy and decisional conflict [ 49 ]. Higher levels of decisional conflict have been associated with end-of-life decisions, whereas advanced directives have been associated with lower decisional conflict [ 5 , 50 , 51 ]. However, lower decisional conflict may also indicate a lack of engagement with hard choices, rather than better decision-making [ 52 ].…”

Development of digital decision aid among surrogate decision makers for critically ill patients requiring renal replacement therapy: a formative research study

“…Although shared decision-making is essential to support patient-centered care [67], evidence suggested that medical necessity and clinicians' sense of patients' best interests still drive the direction of treatment decision making when the stakes are high [13] Unlike previous studies, our DA incorporates the consideration of family-centered care to improve surrogates' participation in and preparation for decision making. The role of surrogate decision makers in critical illness has been indicated with associations of surrogates' decisional dilemmas [10], decisional con icts [12], decisional regrets [70], personal distress [71], high incidence of PTSD-like symptoms [72], and post-ICU syndrome [73]. Cox et al [74] conducted a randomized clinical trial to examine the effects of a web-based DA for surrogate decision makers of patients with prolonged mechanical ventilation in ICU, which showed greater reduction in decisional con ict among surrogates, but with no impact on the improvement of surrogates' psychological distress, prognostic concordance between surrogates and clinicians, or patients' clinical outcomes.…”

“…Despite the relative prevalence of RRT for ICU patients suffering from AKI, it is di cult for family surrogates to nd reliable information about RRT and therefore challenging for them to share in the decision-making process with clinicians [11]. Furthermore, family participation in RRT decision making was uniformly reported as a stressful experience [12], and discrepancies between the values and priorities of the medical system and those of the patient were identi ed [11]. Usually, family surrogates face dilemmas when participating in preference-sensitive decision making for critically ill patients.…”

Development and evaluation of a decision aid for family surrogate decision-makers for patients with acute kidney injury requiring renal replacement therapy (RRT) in ICUs: a study protocol

“…Therefore, decision supports tailored to the unique needs of family surrogate decision makers are needed. [50][51][52][53] For decisions around RRT in the ICU, key points include improving communication and support for surrogates and discussing or clarifying the preferences and values of critically ill patients. [54][55][56] Although our plan will not develop a DA tailored to both surrogates and their loved ones, we expect that our endeavours will provide a reference for future efforts to appropriately involve incapacitated patients in treatment decision making.…”

“…Since most critically ill patients are incapacitated, decision making in the ICU is complex. Therefore, decision supports tailored to the unique needs of family surrogate decision makers are needed 50–53. For decisions around RRT in the ICU, key points include improving communication and support for surrogates and discussing or clarifying the preferences and values of critically ill patients 54–56.…”