Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study
Open Access
- 1 May 2020
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Critical Care Medicine
- Vol. 48 (5), 645-653
- https://doi.org/10.1097/CCM.0000000000004221
Abstract
Objectives: To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries. Design: A three-round web-based international Delphi consensus study with a priori consensus definition was conducted with experts from 13 countries. Participants reviewed items of the decision-making process on a seven-point Likert scale or with open-ended questions. Questions concerned terminology, content, and timing of decision-making steps. The summarized results (including mean scores) and expert suggestions were presented in the subsequent round for review. Setting: Web-based surveys of international participants representing ICU physicians, nurses, former ICU patients, and surrogate decision makers. Patients: Not applicable. Interventions: Not applicable. Measurements and Main Results: In three rounds, respectively, 28, 28, and 27 (of 33 invited) physicians together with 12, 10, and seven (of 19 invited) nurses participated. Patients and surrogates were involved in round one and 12 of 27 responded. Caregivers were mostly working in university affiliated hospitals in Northern Europe. During the Delphi process, most items were modified in order to reach consensus. Seven items lacked consensus after three rounds. The final consensus framework comprises the content and timing of four elements; three elements focused on caregiver-surrogate communication (admission meeting, follow-up meeting, goals-of-care meeting); and one element (weekly time-out meeting) focused on assessing preferences, prognosis, and proportionality of ICU treatment among professionals. Conclusions: Physicians, nurses, patients, and surrogates generated a consensus-based framework to guide the process of decision-making on continuing or limiting life-sustaining treatments in the ICU. Early, frequent, and scheduled family meetings combined with a repeated multidisciplinary time-out meeting may support decisions in relation to patient preferences, prognosis, and proportionality.This publication has 39 references indexed in Scilit:
- Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative studyIntensive Care Medicine, 2013
- Decision-making and safety in anesthesiologyCurrent Opinion In Anesthesiology, 2012
- Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensityIntensive Care Medicine, 2012
- Identifying family members who may struggle in the role of surrogate decision maker*Critical Care Medicine, 2012
- The variability of critical care bed numbers in EuropeIntensive Care Medicine, 2012
- Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practicesIntensive Care Medicine, 2011
- Decision aids for people facing health treatment or screening decisionsPublished by Wiley ,2011
- End-of-life practices in 282 intensive care units: data from the SAPS 3 databaseIntensive Care Medicine, 2008
- A Communication Strategy and Brochure for Relatives of Patients Dying in the ICUThe New England Journal of Medicine, 2007
- Withdrawal of Mechanical Ventilation in Anticipation of Death in the Intensive Care UnitThe New England Journal of Medicine, 2003