Poor Family-Clinician Discussion Burdens ICU Care

Leslie P. Scheunemann, MD, MPH

The process of requesting and understanding an incapacitated patient’s treatment and health preferences may not be a perfected craft in intensive care units (ICUs).

In a secondary analysis of an ICU clinician-family conference cohort study, a team of US-based investigators found that incapacitated patients’ values and preferences were discussed in about two-thirds of relevant discussions between a care provider and a patient’s surrogate.

However, deliberations as to how such values and preferences would be applied to any medical decisions occurred less than half the time. Even worse rates were reported for discussions on patients’ end-of-life considerations.

The team, led by Leslie P. Scheunemann, MD, MPH, of the Division of Geriatric Medicine and Gerontology and Division of Pulmonary, Allergy and Critical Care Medicine at the University of Pittsburgh, believe the findings show a need for improved and consistent communication between care providers and surrogates that represents an incapacitated critically ill patient.

The supplemental analysis of the prospective, multi-center cohort study assessed the audio-recorded conferences between surrogates and clinicians regarding the care of 249 incapacitated, critically ill adults in the ICU. The original study was conducted between October 2009 and October 2012, and the follow-up data analysis was performed from July 2014 to April 2015. Eligible patients lacked a capacity to make decisions regarding their health, an acute respiratory distress syndrome (ARDS) diagnosis, and a predicted hospital mortality of at least 50%.

Their assessment included 451 surrogates and 144 clinicians across 13 ICUS at 6 US-based academic and community medical centers. Investigators analyzed the audio transcripts for statements including information about the patients’ treatment preferences and health-related values, as well as a deliberation by the parties to apply them into treatment planning.

Mean patient age was 58.2 years old, with 134 (54.9%) of patients being men. Investigators reported that, of the 244 conferences to address a decision about patient treatment goals, 167 (68.4% [95% CI: 62.6-74.3]) included an exchange on the patients’ values and preferences. More conferences specifically deliberated as to how these values applied to decision-making (108; 44.3%) than conferences which contained no information about patient preference and value at all (63; 25.8%).

End-of-life considerations—which included physical, cognitive, and social functioning, and patient spirituality—were discussed in just 87 (35.7%) conferences. In just 33 (13.5%) conferences did the surrogate provide a substituted judgement for the patient, and in only 20 (8.2%) did a clinician make a treatment recommendation based on the patients’ values and preferences.

In an editorial accompanying the study, Terri R. Fried, MD, of the Clinical Epidemiology Research Center at the Veterans Affair Connecticut Healthcare System, and Department of Medicine at Yale School of Medicine, called the study’s findings an “invaluable window” into how shared decision making plays out in the ICU.

“By providing a more comprehensive summary of the communication leading to those decisions, the article expands on the prior research to yield important insights about how best to move forward to improve decision making,” Fried noted. “It has been shown that it is possible to improve clinicians’ skills for conducting goals of care discussions.”

Fried suggested that, rather than focusing on clinician-surrogate conferences as a shared understanding of values, the 2 parties should instead pursue a shared understanding of the decision to be made. While clinicians often focus their description on the treatment characteristics or their planned process of care, patients often emphasize the outcome of the treatment. As such, clinicians could fare better from emphasizing treatment outcomes—not just in terms of mortality, but in quality-of-life metrics as well.

“This explicit presentation of outcomes clarifies the different trade-offs among the alternatives, which, in turn, can help surrogates understand the relevance of the patient’s values and goals and focus on the ones that best inform the decision,” Fried wrote.

Scheunemann and colleagues concluded that, if clinicians and surrogates are unable to reach a shared understanding the patients’ values and preferences, the treatment strategy is also likely to struggle. As such, improved interventions which train clinicians to facilitate conversations that allow surrogates to properly represent patients are needed moving forward.

“For now, we recommend that clinicians should ask questions and recommend treatment based on their best understanding of how patients would feel about their expected lifestyle and functioning after critical illness,” investigators wrote.

The study, "Clinician-Family Communication About Patients’ Values and Preferences in Intensive Care Units," was published online in JAMA Internal Medicine.