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Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation: A Randomized Clinical Trial.
Ann Intern Med. 2019 03 05; 170(5):285-297.AIM

Abstract

Background

Treatment decisions commonly have to be made in intensive care units (ICUs). These decisions are difficult for surrogate decision makers and often lead to decisional conflict, psychological distress, and treatments misaligned with patient preferences.

Objective

To determine whether a decision aid about prolonged mechanical ventilation improved prognostic concordance between surrogate decision makers and clinicians compared with a usual care control.

Design

Multicenter, parallel, randomized, clinical trial. (ClinicalTrials.gov: NCT01751061).

Setting

13 medical and surgical ICUs at 5 hospitals.

Participants

Adult patients receiving prolonged mechanical ventilation and their surrogates, ICU physicians, and ICU nurses.

Intervention

A Web-based decision aid provided personalized prognostic estimates, explained treatment options, and interactively clarified patient values to inform a family meeting. The control group received information according to usual care practices followed by a family meeting.

Measurements

The primary outcome was improved concordance on 1-year survival estimates, measured with the clinician-surrogate concordance scale (range, 0 to 100 percentage points; higher scores indicate more discordance). Secondary and additional outcomes assessed the experiences of surrogates (psychological distress, decisional conflict, and quality of communication) and patients (length of stay and 6-month mortality). Outcomes assessors were blinded to group allocation.

Results

The study enrolled 277 patients, 416 surrogates, and 427 clinicians. Concordance improvement did not differ between intervention and control groups (mean difference in score change from baseline, -1.7 percentage points [95% CI, -8.3 to 4.8 percentage points]; P = 0.60). Surrogates' postintervention estimates of patients' 1-year prognoses did not differ between intervention and control groups (median, 86.0% [interquartile range {IQR}, 50.0%] vs. 92.5% [IQR, 47.0%]; P = 0.23) and were substantially more optimistic than results of a validated prediction model (median, 56.0% [IQR, 43.0%]) and physician estimates (median, 50.0% [IQR, 55.5%]). Eighty-two intervention surrogates (43%) favored a treatment option that was more aggressive than their report of patient preferences. Although intervention surrogates had greater reduction in decisional conflict than control surrogates (mean difference in change from baseline, 0.4 points [CI, 0.0 to 0.7 points]; P = 0.041), other surrogate and patient outcomes did not differ.

Limitation

Contamination among clinicians could have biased results toward the null hypothesis.

Conclusion

A decision aid about prolonged mechanical ventilation did not improve prognostic concordance between clinicians and surrogates, reduce psychological distress among surrogates, or alter clinical outcomes. Decision support in acute care settings may require greater individualized attention for both the cognitive and affective challenges of decision making.

Primary Funding Source

National Institutes of Health.

Authors+Show Affiliations

Duke University, Durham, North Carolina (C.E.C., D.M.J.).University of Pittsburgh, Pittsburgh, Pennsylvania (D.B.W., J.M.K.).University of Washington, Seattle, Washington (C.L.H.).Duke University, Durham, North Carolina (C.E.C., D.M.J.).University of Pittsburgh, Pittsburgh, Pennsylvania (D.B.W., J.M.K.).Duke University and the Center for Health Services Research in Primary Care at the Durham VA Medical Center, Durham, North Carolina (M.K.O.).University of Colorado, Aurora, Colorado (C.L.L.).University of North Carolina, Chapel Hill, North Carolina (L.C.H., S.S.C.).University of North Carolina, Chapel Hill, North Carolina (L.C.H., S.S.C.).

Pub Type(s)

Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

30690645

Citation

Cox, Christopher E., et al. "Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation: a Randomized Clinical Trial." Annals of Internal Medicine, vol. 170, no. 5, 2019, pp. 285-297.
Cox CE, White DB, Hough CL, et al. Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation: A Randomized Clinical Trial. Ann Intern Med. 2019;170(5):285-297.
Cox, C. E., White, D. B., Hough, C. L., Jones, D. M., Kahn, J. M., Olsen, M. K., Lewis, C. L., Hanson, L. C., & Carson, S. S. (2019). Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation: A Randomized Clinical Trial. Annals of Internal Medicine, 170(5), 285-297. https://doi.org/10.7326/M18-2335
Cox CE, et al. Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation: a Randomized Clinical Trial. Ann Intern Med. 2019 03 5;170(5):285-297. PubMed PMID: 30690645.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation: A Randomized Clinical Trial. AU - Cox,Christopher E, AU - White,Douglas B, AU - Hough,Catherine L, AU - Jones,Derek M, AU - Kahn,Jeremy M, AU - Olsen,Maren K, AU - Lewis,Carmen L, AU - Hanson,Laura C, AU - Carson,Shannon S, Y1 - 2019/01/29/ PY - 2019/1/29/pubmed PY - 2019/12/26/medline PY - 2019/1/29/entrez SP - 285 EP - 297 JF - Annals of internal medicine JO - Ann. Intern. Med. VL - 170 IS - 5 N2 - Background: Treatment decisions commonly have to be made in intensive care units (ICUs). These decisions are difficult for surrogate decision makers and often lead to decisional conflict, psychological distress, and treatments misaligned with patient preferences. Objective: To determine whether a decision aid about prolonged mechanical ventilation improved prognostic concordance between surrogate decision makers and clinicians compared with a usual care control. Design: Multicenter, parallel, randomized, clinical trial. (ClinicalTrials.gov: NCT01751061). Setting: 13 medical and surgical ICUs at 5 hospitals. Participants: Adult patients receiving prolonged mechanical ventilation and their surrogates, ICU physicians, and ICU nurses. Intervention: A Web-based decision aid provided personalized prognostic estimates, explained treatment options, and interactively clarified patient values to inform a family meeting. The control group received information according to usual care practices followed by a family meeting. Measurements: The primary outcome was improved concordance on 1-year survival estimates, measured with the clinician-surrogate concordance scale (range, 0 to 100 percentage points; higher scores indicate more discordance). Secondary and additional outcomes assessed the experiences of surrogates (psychological distress, decisional conflict, and quality of communication) and patients (length of stay and 6-month mortality). Outcomes assessors were blinded to group allocation. Results: The study enrolled 277 patients, 416 surrogates, and 427 clinicians. Concordance improvement did not differ between intervention and control groups (mean difference in score change from baseline, -1.7 percentage points [95% CI, -8.3 to 4.8 percentage points]; P = 0.60). Surrogates' postintervention estimates of patients' 1-year prognoses did not differ between intervention and control groups (median, 86.0% [interquartile range {IQR}, 50.0%] vs. 92.5% [IQR, 47.0%]; P = 0.23) and were substantially more optimistic than results of a validated prediction model (median, 56.0% [IQR, 43.0%]) and physician estimates (median, 50.0% [IQR, 55.5%]). Eighty-two intervention surrogates (43%) favored a treatment option that was more aggressive than their report of patient preferences. Although intervention surrogates had greater reduction in decisional conflict than control surrogates (mean difference in change from baseline, 0.4 points [CI, 0.0 to 0.7 points]; P = 0.041), other surrogate and patient outcomes did not differ. Limitation: Contamination among clinicians could have biased results toward the null hypothesis. Conclusion: A decision aid about prolonged mechanical ventilation did not improve prognostic concordance between clinicians and surrogates, reduce psychological distress among surrogates, or alter clinical outcomes. Decision support in acute care settings may require greater individualized attention for both the cognitive and affective challenges of decision making. Primary Funding Source: National Institutes of Health. SN - 1539-3704 UR - https://www.unboundmedicine.com/medline/citation/30690645/Effects_of_a_Personalized_Web_Based_Decision_Aid_for_Surrogate_Decision_Makers_of_Patients_With_Prolonged_Mechanical_Ventilation:_A_Randomized_Clinical_Trial_ L2 - https://www.annals.org/aim/fullarticle/doi/10.7326/M18-2335 DB - PRIME DP - Unbound Medicine ER -