Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study

Abstract

Objectives: To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries. Design: A three-round web-based international Delphi consensus study with a priori consensus definition was conducted with experts from 13 countries. Participants reviewed items of the decision-making process on a seven-point Likert scale or with open-ended questions. Questions concerned terminology, content, and timing of decision-making steps. The summarized results (including mean scores) and expert suggestions were presented in the subsequent round for review. Setting: Web-based surveys of international participants representing ICU physicians, nurses, former ICU patients, and surrogate decision makers. Patients: Not applicable. Interventions: Not applicable. Measurements and Main Results: In three rounds, respectively, 28, 28, and 27 (of 33 invited) physicians together with 12, 10, and seven (of 19 invited) nurses participated. Patients and surrogates were involved in round one and 12 of 27 responded. Caregivers were mostly working in university affiliated hospitals in Northern Europe. During the Delphi process, most items were modified in order to reach consensus. Seven items lacked consensus after three rounds. The final consensus framework comprises the content and timing of four elements; three elements focused on caregiver-surrogate communication (admission meeting, follow-up meeting, goals-of-care meeting); and one element (weekly time-out meeting) focused on assessing preferences, prognosis, and proportionality of ICU treatment among professionals. Conclusions: Physicians, nurses, patients, and surrogates generated a consensus-based framework to guide the process of decision-making on continuing or limiting life-sustaining treatments in the ICU. Early, frequent, and scheduled family meetings combined with a repeated multidisciplinary time-out meeting may support decisions in relation to patient preferences, prognosis, and proportionality.

Physicians’ perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study

“…The use of short-cuts in admission decisions contrasts with the process advocated to decide about limiting or not life-sustaining treatments in the ICU. 9 It reflects the time-pressured context of triage when repeated meetings with the family and among the healthcare professionals are hardly feasible and when prognostic uncertainty is high. To admit a patient in case of great uncertainty is consistent with professional guidelines that deem overtriage to be more acceptable than undertriage.…”

“… 7 The lack of specific criteria for ICU admission decisions has been recently pointed out. 8 Whereas a decision supporting framework was developed to address the issue of limiting or not life-sustaining treatments in the ICU, 9 no such framework exists for triage. Yet, deciding whether to admit a patient to the ICU is often complex, and physicians mostly rely on their clinical judgement.…”

Delphi-endorsed Communication Skills Clinicians Need to Care for Hospitalized Incapacitated Patients

“…The final set of expert-endorsed communication skills underscores the overwhelming importance of interactive and affective skills, as opposed to solely information delivery skills. These findings suggest that decision support paradigms emphasizing information delivery and deliberation ( 22 ) must ensure that emotional and psychological support are integrated throughout the process of serious illness decision-making. Finally, our findings add to the published literature through the endorsement of skills that are specific to different conversation prototypes, rather than those focused exclusively on outpatient advance care planning or inpatient end-of-life conversations.…”

“…To our knowledge, this is the first study to apply a systematic, deductive methodology to produce an expert-endorsed set of core communication skills for conversations with surrogates of hospitalized, incapacitated patients, and it is the first to address skills pertinent to communication with the surrogates of hospitalized patients with ADRD. One other related Delphi study was recently conducted; however, its purpose was to identify a process (including content elements and timing) for decision making, and it was focused solely on life-sustaining treatment in the intensive care unit setting ( 22 ).…”

Ethisch begründet entscheiden in der Intensivmedizin

“…Es gründet auf einer Indikationsstellung entsprechend aktueller Evidenz hinsichtlich der Prognose und der Gesamtsituation 2 , 6 , 7 , 8 .…”