Physician Self-assessment of Shared Decision-making in Simulated Intensive Care Unit Family Meetings

Abstract

IMPORTANCE Professional guidelines have identified key communication skills for shared decisionmaking for critically ill patients, but it is unclear how intensivists interpret and implement them.OBJECTIVE To compare the self-evaluations of intensivists reviewing transcripts of their own simulated intensive care unit family meetings with the evaluations of trained expert colleagues. DESIGN, SETTING, AND PARTICIPANTSA posttrial web-based survey of intensivists was conducted between January and March 2019. Intensivists reviewed transcripts of simulated intensive care unit family meetings in which they participated in a previous trial from October 2016 to November 2017. In the follow-up survey, participants identified if and how they performed key elements of shared decision-making for an intensive care unit patient at high risk of death. Transcript texts that intensivists self-identified as examples of key communication skills recommended by their professional society's policy on shared decision-making were categorized. MAIN OUTCOMES AND MEASURES Comparison of the evaluations of 2 blinded nonparticipant intensivist colleagues with the self-reported responses of the intensivists. RESULTS Of 116 eligible intensivists, 76 (66%) completed the follow-up survey (mean [SD]respondent age was 43.1 [8.1] years; 72% were male). Sixty-one of 76 intensivists reported conveying prognosis; however, blinded colleagues who reviewed the deidentified transcripts were less likely to report that prognosis had been conveyed than intensivists reviewing their own transcripts (42 of 61; odds ratio, 0.10; 95% CI, 0.01-0.44; P < .001). When reviewing their own transcript, intensivists reported presenting many choices, with the most common choice being code status. They also provided a variety of recommendations, with the most common being to continue the current treatment plan. Thirty-three participants (43%) reported that they offered care focused on comfort, but blinded colleagues rated only 1 (4%) as explaining this option in a clear manner. CONCLUSIONS AND RELEVANCEIn this study, guidelines for shared decision-making and end of life care were interpreted by intensivists in disparate ways. In the absence of training or personalized feedback, self-assessment of communication skills may not be interpreted consistently.

The Perspectives of Surrogates and Healthcare Providers Regarding SDM (Shared Decision-Making)

“…Based on the interview responses, we identified heavy workload and insufficient communication time of healthcare providers as obstacles affecting the implementation of SDM. In a previous study, insufficient communication time and interruption of intervention were identified as major obstacles faced by ICU healthcare providers for implementing SDM [ 20 ]. Lots of research institutions are constantly refining the implementation process of SDM and developing different decision aid tools.…”

Intensivists’ perceptions of what is missing in their compassionate care during interactions in the intensive care unit

“…These are elicitation skills that will enrich cognitive empathy. A recent study by Vasher, et al suggested that the self-assessment of clinicians who lack communication skills did not agree with those of external-intensivist raters and they may also lack the “metacognitive skills required to recognize their deficiencies.” [ 22 ] Expressive skills such as acknowledgment, partnership, and validation of emotions convey empathic concern and compassion [ 23 ]. While respondents rated their skills highly on average, their top-box scores are contrary to this finding, as most participants were able to grade the nuances of their compassionate care and highlight areas where further enhancement was needed.…”

Shared decision-making in the ICU from the perspective of physicians, nurses and patients: a qualitative interview study

“…Earlier literature into the subject shows a focus on decisions pertaining to end-of-life. 15 31 37 38 This decision is sometimes viewed as one of the main and most difficult decisions to be made in the ICU, so much so that clinician interviewees oftentimes presumed it to be the natural focus point of the interview. Consistently, there was a variety of interpretations regarding what SDM in the ICU looked like.…”

“…Consistently, there was a variety of interpretations regarding what SDM in the ICU looked like. This signals a possible need for training and role models 15 39 40 to improve both clinician–patient and interprofessional understanding and execution of SDM.…”