The Facilitated Values History

Self Cite

413

134

Objectives Shared decision-making (SDM) is endorsed by critical care organizations, however there remains confusion about what SDM is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define SDM, recommend when SDM should be used, identify the range of ethically acceptable decision-making models, and present important communication skills. Methods The American College of Critical Care Medicine (ACCM) and American Thoracic Society (ATS) Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of ACCM and ATS were included in the statement. Main Results Six recommendations were endorsed: 1) Definition: Shared decision-making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals, and preferences. 2) Clinicians should engage in a SDM process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their “default” approach a SDM process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies. Conclusions Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.

Section: Methodsmentioning

confidence: 99%

Shared Decision Making in ICUs

Kon

Davidson

Morrison

et al. 2016

Self Cite

413

134

“…We identified the communication skills of interest based on literature review (10, 15, 16) and a published conceptual framework for values elicitation during end-of-life decision-making. (17) Table E1 (Supplemental Digital Content 1) in the electronic supplement defines its key terms. To ensure content validity, we circulated it among experts in surrogate decision-making and presented it to clinicians at the University of Pittsburgh Medical Center whose practice involves surrogate decision-making.…”

Section: Methodsmentioning

confidence: 99%

How Clinicians Discuss Critically Ill Patients’ Preferences and Values With Surrogates

Scheunemann

Cunningham

Arnold

et al. 2015

Self Cite

Objective Although shared decision-making requires clinicians to discuss the patient’s values and preferences, little is known about the extent to which this occurs with surrogates in intensive care units. We sought to assess whether and how clinicians talk with surrogates about incapacitated patients’ preferences and values. Design Prospective, cross-sectional study. Setting Five ICUs of two hospitals. Subjects Fifty-four physicians and 159 surrogates for 71 patients. Interventions We audio-recorded 71 conferences in which clinicians and surrogates discussed life sustaining treatment decisions for an incapacitated patient near the end of life. Two coders independently coded each instance in which clinicians or surrogates discussed the patient’s previously expressed treatment preferences or values. They subcoded for values that are commonly important to patients near the end of life. They also coded treatment recommendations by clinicians that incorporated the patient’s preferences or values. Measurements and Main Results In 30% of conferences, there was no discussion about the patient’s previously expressed preferences or values. In 37%, clinicians and surrogates discussed both the patient’s treatment preferences and values. In the remaining 33%, clinicians and surrogates discussed either the patient’s treatment preferences or values, but not both. In >88% of conferences, there was no conversation about the patient’s values regarding autonomy and independence, emotional well-being and relationships, physical function, cognitive function, or spirituality. On average, 3.8% (SD 4.3, range 0 – 16%) of words spoken pertained to patient preferences or values. Conclusions In roughly a third of ICU family conferences for patients at high risk of death, neither clinicians nor surrogates discussed patients’ preferences or values about end-of-life decision-making. In <12% of conferences did participants address values of high importance to most patients, such as cognitive and physical function. Interventions are needed to ensure patients’ values and preferences are elicited and integrated into end-of-life decisions in ICUs.

“…[55] From the time of admission, available prognostic information, and all indicated treatment options should be openly discussed, along with a review of prior advance care planning so that the patient's wishes are respected. For patients without an advance directive, it is reasonable to initiate a time-limited trial of full intensive care therapy, except in extreme circumstances (e.g., brain death, poor premorbid function, low probability of successful intervention, and factors listed in Table 2).…”

Section: Introductionmentioning

confidence: 99%

“…Table 4 outlines an approach that facilitates discussion of a patient's values as the basis for decision-making. [55] Putting the physician's prognostic estimate of neurological outcome together with the patient's goals and values allows for a process of shared decision-making to develop a plan of care (Figure 2). …”

Section: Introductionmentioning

confidence: 99%

Integrating Palliative Care Into the Care of Neurocritically Ill Patients

Frontera

Curtis

Nelson

et al. 2015

103

Objectives To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; To discuss key prognostic aids and their limitations for neurocritical illnesses; To review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; To describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. Data Sources A search of Pubmed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term “palliative care,” “supportive care,” “end-of-life care,” “withdrawal of life-sustaining therapy,” “limitation of life support,” “prognosis,” or “goals of care” together with “neurocritical care,” “neurointensive care,” “neurological,” “stroke,” “subarachnoid hemorrhage,” “intracerebral hemorrhage,” or “brain injury.” Data Extraction and Synthesis We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert Advisory Board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. Conclusions Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support, will provide clinicians a framework to address decision-making at a time of crisis that enhances patient/family autonomy and clinician professionalism.