April 16th, 2019
Patients in the intensive care unit (ICU) face severe and often life-threatening illnesses. These patients or their families may have to make extremely tough decisions about how to handle a poor prognosis, making the ICU an especially important setting for shared decision making. Although professional organizations emphasize the importance of shared decision making for critically ill patients, little is known about how well clinicians in the ICU incorporate patients’ values into treatment decisions.
A recent study in JAMA Internal Medicine from Dr. Leslie P. Scheunemann at the University of Pittsburgh Medical Center and others found that we still have a long way to go when it comes to making shared decisions in the ICU. The researchers analyzed about 250 conversations between clinicians and families in the ICU and found that very few (8%) resulted in treatment recommendations that were based on patients’ values and preferences.
Let’s be clear — shared decision making, especially in situations where the patient is incapacitated, is very difficult to do. Not only do clinicians have to ask families about what they believe are the patient’s goals and values, clinicians then have to apply this information to the treatment decision(s) at hand (see the table below for examples of these steps from the study).
While most conversations (68.4%) included an exchange of information about the patient’s values and preferences (how the patient felt about invasive procedures to extend life, losing physical or cognitive function, etc.), far fewer conversations included a discussion of how the patient would feel about their current prognosis and treatment options. As Yale School of Medicine professor Dr. Terry Fried points out in an accompanying commentary in JAMA IM, discussions about treatment decisions in the study were usually focused on dying versus prolonged life support, “only rarely considering other outcomes of intensive care, such as physical and cognitive impairment.”
How can we improve shared decision making conversations in the ICU? It will certainly require more training in communication, but may also necessitate a reframing of shared decision making itself within the medical field. We should think of these decisions as starting with “a shared understanding of the decision to be made” rather than a discussion of values, writes Fried.
Additionally, expanding the focus of the decision beyond simply life and death is important. Fried recommends that clinicians’ descriptions of the treatment decision include not only whether or not the patient will survive, “but also the likelihood of physical and cognitive disabilities, ongoing symptoms, ability to live independently, need for ongoing care, and other dimensions that… may be more important to patients than their length of life”