Communication Practices in Physician Decision-Making for an Unstable Critically Ill Patient with End-Stage Cancer

Alexander, Stewart C.; Garrigues, Sarah K.; Arnold, Robert M.; Barnato, Amber E.

doi:10.1089/jpm.2010.0053

Cited by 31 publications

(25 citation statements)

References 30 publications

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“…Previous quantitative studies have reported a single dichotomous measure for whether any preference or values elicitation occurred. (25–28) By measuring each behavior separately, we have added substantial detail to what is known about how clinicians elicit preferences and values in ICU family conferences. Notably, although several interventions have been designed to increase values elicitation,(28–33) only one has measured it in the intervention group,(28) and none has measured it in a control.…”

Section: Discussionmentioning

confidence: 99%

How Clinicians Discuss Critically Ill Patients’ Preferences and Values With Surrogates

Scheunemann

Cunningham

Arnold

et al. 2015

Critical Care Medicine

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Objective Although shared decision-making requires clinicians to discuss the patient’s values and preferences, little is known about the extent to which this occurs with surrogates in intensive care units. We sought to assess whether and how clinicians talk with surrogates about incapacitated patients’ preferences and values. Design Prospective, cross-sectional study. Setting Five ICUs of two hospitals. Subjects Fifty-four physicians and 159 surrogates for 71 patients. Interventions We audio-recorded 71 conferences in which clinicians and surrogates discussed life sustaining treatment decisions for an incapacitated patient near the end of life. Two coders independently coded each instance in which clinicians or surrogates discussed the patient’s previously expressed treatment preferences or values. They subcoded for values that are commonly important to patients near the end of life. They also coded treatment recommendations by clinicians that incorporated the patient’s preferences or values. Measurements and Main Results In 30% of conferences, there was no discussion about the patient’s previously expressed preferences or values. In 37%, clinicians and surrogates discussed both the patient’s treatment preferences and values. In the remaining 33%, clinicians and surrogates discussed either the patient’s treatment preferences or values, but not both. In >88% of conferences, there was no conversation about the patient’s values regarding autonomy and independence, emotional well-being and relationships, physical function, cognitive function, or spirituality. On average, 3.8% (SD 4.3, range 0 – 16%) of words spoken pertained to patient preferences or values. Conclusions In roughly a third of ICU family conferences for patients at high risk of death, neither clinicians nor surrogates discussed patients’ preferences or values about end-of-life decision-making. In <12% of conferences did participants address values of high importance to most patients, such as cognitive and physical function. Interventions are needed to ensure patients’ values and preferences are elicited and integrated into end-of-life decisions in ICUs.

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Section: Discussionmentioning

confidence: 99%

How Clinicians Discuss Critically Ill Patients’ Preferences and Values With Surrogates

Scheunemann

Cunningham

Arnold

et al. 2015

Critical Care Medicine

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“…While studies of shared decision making at the end of life have focused on the content of communication, 4,5,14 less is known about the language used by physicians in these discussions. A recent study by Dieltjens et al evaluating conversations between physicians and patients requesting physician-assisted suicide in the Netherlands 15 analyzed communication style at the level of grammatical expression.…”

Section: Discussionmentioning

confidence: 99%

“…1 Key elements of shared decision making include sharing medical information, eliciting patient values and preferences, and developing consensus on a treatment plan. 2,3 Prior studies of shared decision making in the ICU setting 4,5 have described the frequency with which physicians use these elements in discussions about end-of-life treatment decisions. For example, White et al found that physicians described treatment alternatives in 80% of physician-family conferences.…”

Section: Introductionmentioning

confidence: 99%

The Language of End-of-Life Decision Making: A Simulation Study

Alexander

Mescher

et al. 2015

Journal of Palliative Medicine

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Background: Framing is known to influence decision making. Objective: The study objective was to describe language used by physicians when discussing treatment options with a critically and terminally ill elder. Methods: High-fidelity simulation was used, involving an elder with end-stage cancer and life-threatening hypoxia, followed by a debriefing interview. Subjects were hospitalist, emergency medicine, and critical care physicians from three academic medical centers. Measures were observation of encounters in real time followed by content analysis of simulation and debriefing interview transcripts. During the simulation we identified the first mention (''broaching'') of principal treatment options-intubation and mechanical ventilation (lifesustaining treatment [LST]) and palliation in anticipation of death (palliation)-and used constant comparative methods to identify language used. We identified physician opinions about the use of LST in this clinical context during the debriefing interviews, and compared language used with opinions. Results: Among 114 physician subjects, 106 discussed LST, 86 discussed palliation, and 84 discussed both. We identified five frames: will (decided), must (necessary), should (convention), could (option), and ask (elicitation of preferences). Physicians broached LST differently than palliation ( p < 0.01), most commonly framing LST as necessary (53%), while framing palliation as optional (49%). Among physicians who framed LST as imperative (will or must), 16 (30%) felt intubation would be inappropriate in this clinical situation. Conclusions: In this high-fidelity simulation experiment involving a critically and terminally ill elder, the majority of physicians framed the available options in ways implying LST was the expected or preferred choice. Framing of treatment options could influence ultimate treatment decisions.

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“…We have previously reported descriptive analyses of emotion-handling and general communication behaviors of 27 of the 98 subject physicians[7]. …”

Section: Methodsmentioning

confidence: 99%

Physicians’ Decision-Making Roles for an Acutely Unstable Critically and Terminally Ill Patient*

White

Mohan

et al. 2013

Critical Care Medicine

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Background There is substantial variation in use of life sustaining technologies in patients near the end of life but little is known about variation in physicians’ initial ICU admission and intubation decision making processes. Objective To describe variation in hospital-based physicians’ communication behaviors and decision making roles for ICU admission and intubation decisions for an acutely unstable critically and terminally ill patient. Methods We conducted a secondary analysis of transcribed simulation encounters from a multi-center observational study of physician decision making. The simulation depicted a 78 year-old man with metastatic gastric cancer and life threatening hypoxia. He has stable underlying preferences against ICU admission and intubation that he or his wife will report if asked. We coded encounters for communication behaviors (providing medical information, eliciting preferences/values, engaging the patient/surrogate in deliberation, and providing treatment recommendations) and used a previously-developed framework to classify subject physicians into four mutually-exclusive decision-making roles: informative (providing medical information only), facilitative (information + eliciting preferences/values + guiding surrogate to apply preferences/values), collaborative (information + eliciting + guiding + making a recommendation) and directive (making an independent treatment decision). Subjects 24 emergency physicians, 37 hospitalists, and 37 intensivists from 3 US academic medical centers. Results Subject physicians average 12.4 (SD 9.0) years since graduation from medical school. 38/98(39%) physicians sent the patient to the ICU, and 9/98(9%) ultimately decided to intubate. Most (93/98 (95%)) provided at least some medical information, but few explained the short-term prognosis with (26/98 (27%)) or without intubation (37/98 (38%)). Many (80/98 (82%)) elicited the patient's intubation preferences, but few (35/98 (36%)) explored the patient's broader values. Based on coded behaviors, we categorized 1/98 (1%) as informative, 48/98 (49%) as facilitative, 36/98 (37%) as collaborative, and 12/98 (12%) as directive; 1/98 (1%) could not be placed into a category. No observed physician characteristics predicted decision making role. Conclusions The majority of the physicians played a facilitative or collaborative role, although a greater proportion assumed a directive role in this time-pressured scenario than has been documented in non-time pressured ICU family meetings, suggesting that physicians’ roles may be context-dependent.

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Communication Practices in Physician Decision-Making for an Unstable Critically Ill Patient with End-Stage Cancer

Cited by 31 publications

References 30 publications

How Clinicians Discuss Critically Ill Patients’ Preferences and Values With Surrogates

How Clinicians Discuss Critically Ill Patients’ Preferences and Values With Surrogates

The Language of End-of-Life Decision Making: A Simulation Study

Physicians’ Decision-Making Roles for an Acutely Unstable Critically and Terminally Ill Patient*

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