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Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units.
JAMA Intern Med. 2019 05 01; 179(5):676-684.JIM

Abstract

Importance

Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating intensive care unit (ICU) patients' values and preferences into treatment decisions.

Objectives

To determine how often clinicians and surrogates exchange information about patients' previously expressed values and preferences and deliberate and plan treatment based on these factors during conferences about prognosis and goals of care for incapacitated ICU patients.

Design, Setting, and Participants

A secondary analysis of a prospective, multicenter cohort study of audiorecorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults was conducted. The study was performed between October 8, 2009, and October 23, 2012. Data analysis was performed between July 2, 2014, and April 20, 2015. Patient eligibility criteria included lack of decision-making capacity, a diagnosis of acute respiratory distress syndrome, and predicted in-hospital mortality of 50% or more. In addition to the patients, 451 surrogates and 144 clinicians at 13 ICUs at 6 US academic and community medical centers were included.

Main Outcomes and Measures

Two coders analyzed transcripts of audiorecorded conversations for statements in which clinicians and surrogates exchanged information about patients' treatment preferences and health-related values and applied them in deliberation and treatment planning.

Results

Of the 249 patients, 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%; 95% CI, 20.3%-31.3%) contained no information exchange or deliberation about patients' values and preferences. Clinicians and surrogates exchanged information about patients' values and preferences in 167 (68.4%) (95% CI, 62.6%-74.3%) of the conferences and specifically deliberated about how the patients' values applied to the decision in 108 (44.3%; 95% CI, 38.0%-50.5%). Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 87 (35.7%) or less of the conferences; surrogates provided a substituted judgment in 33 (13.5%); and clinicians made treatment recommendations based on patients' values and preferences in 20 conferences (8.2%).

Conclusions and Relevance

Most clinician-family conferences about prognosis and goals of care for critically ill patients appear to lack important elements of communication about values and preferences, with robust deliberation being particularly deficient. Interventions may be needed to better prepare surrogates for these conversations and improve clinicians' communication skills for eliciting and incorporating patients' values and preferences into treatment decisions.

Authors+Show Affiliations

Division of Geriatric Medicine and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania. Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.Department of Health Policy and Management, University of North Carolina at Chapel Hill.Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill.Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle.Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle. Cambia Palliative Care Center of Excellence, University of Washington, Seattle.Palliative Care Program, University of California, San Francisco Medical Center, San Francisco. Division of Hospital Medicine, University of California, San Francisco School of Medicine, San Francisco. Department of Physiological Nursing, University of California, San Francisco School of Nursing, San Francisco.Division of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield.The Greenwall Foundation, New York, New York.Departments of Medicine and Anesthesia and Perioperative Care, University of California, San Francisco.Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania. Palliative and Supportive Institute, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania.Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

30933293

Citation

Scheunemann, Leslie P., et al. "Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units." JAMA Internal Medicine, vol. 179, no. 5, 2019, pp. 676-684.
Scheunemann LP, Ernecoff NC, Buddadhumaruk P, et al. Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units. JAMA Intern Med. 2019;179(5):676-684.
Scheunemann, L. P., Ernecoff, N. C., Buddadhumaruk, P., Carson, S. S., Hough, C. L., Curtis, J. R., Anderson, W. G., Steingrub, J., Lo, B., Matthay, M., Arnold, R. M., & White, D. B. (2019). Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units. JAMA Internal Medicine, 179(5), 676-684. https://doi.org/10.1001/jamainternmed.2019.0027
Scheunemann LP, et al. Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units. JAMA Intern Med. 2019 05 1;179(5):676-684. PubMed PMID: 30933293.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units. AU - Scheunemann,Leslie P, AU - Ernecoff,Natalie C, AU - Buddadhumaruk,Praewpannarai, AU - Carson,Shannon S, AU - Hough,Catherine L, AU - Curtis,J Randall, AU - Anderson,Wendy G, AU - Steingrub,Jay, AU - Lo,Bernard, AU - Matthay,Michael, AU - Arnold,Robert M, AU - White,Douglas B, PY - 2019/4/2/pubmed PY - 2020/2/18/medline PY - 2019/4/2/entrez SP - 676 EP - 684 JF - JAMA internal medicine JO - JAMA Intern Med VL - 179 IS - 5 N2 - Importance: Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating intensive care unit (ICU) patients' values and preferences into treatment decisions. Objectives: To determine how often clinicians and surrogates exchange information about patients' previously expressed values and preferences and deliberate and plan treatment based on these factors during conferences about prognosis and goals of care for incapacitated ICU patients. Design, Setting, and Participants: A secondary analysis of a prospective, multicenter cohort study of audiorecorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults was conducted. The study was performed between October 8, 2009, and October 23, 2012. Data analysis was performed between July 2, 2014, and April 20, 2015. Patient eligibility criteria included lack of decision-making capacity, a diagnosis of acute respiratory distress syndrome, and predicted in-hospital mortality of 50% or more. In addition to the patients, 451 surrogates and 144 clinicians at 13 ICUs at 6 US academic and community medical centers were included. Main Outcomes and Measures: Two coders analyzed transcripts of audiorecorded conversations for statements in which clinicians and surrogates exchanged information about patients' treatment preferences and health-related values and applied them in deliberation and treatment planning. Results: Of the 249 patients, 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%; 95% CI, 20.3%-31.3%) contained no information exchange or deliberation about patients' values and preferences. Clinicians and surrogates exchanged information about patients' values and preferences in 167 (68.4%) (95% CI, 62.6%-74.3%) of the conferences and specifically deliberated about how the patients' values applied to the decision in 108 (44.3%; 95% CI, 38.0%-50.5%). Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 87 (35.7%) or less of the conferences; surrogates provided a substituted judgment in 33 (13.5%); and clinicians made treatment recommendations based on patients' values and preferences in 20 conferences (8.2%). Conclusions and Relevance: Most clinician-family conferences about prognosis and goals of care for critically ill patients appear to lack important elements of communication about values and preferences, with robust deliberation being particularly deficient. Interventions may be needed to better prepare surrogates for these conversations and improve clinicians' communication skills for eliciting and incorporating patients' values and preferences into treatment decisions. SN - 2168-6114 UR - https://www.unboundmedicine.com/medline/citation/30933293/Clinician_Family_Communication_About_Patients'_Values_and_Preferences_in_Intensive_Care_Units_ L2 - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2019.0027 DB - PRIME DP - Unbound Medicine ER -