Prior Advance Care Planning Is Associated with Less Decisional Conflict among Surrogates for Critically Ill Patients

Abstract

Rationale: Although numerous studies have documented that family members in intensive care units struggle with end-of-life decisions for incapacitated patients, there is little information about whether prior advance care planning lessens the burden of decision making.Objectives: We sought to measure decisional conflict in surrogates of critically ill patients and to examine whether prior advance care planning is associated with less decisional conflict. Methods:We performed a secondary data analysis of a multicenter, prospective cohort study done at five U.S. academic medical centers that included 471 surrogates of 257 patients with acute respiratory distress syndrome. The main outcome was surrogates' burden of decision making as measured using the Decisional Conflict Scale. Surrogates completed a questionnaire item addressing whether they had had any prior advance care planning conversations with their loved ones. We used multilevel linear regression modeling to measure the association between decisional conflict and advance care planning. Measurements and Main Results:Moderate or high levels of decisional conflict (Decisional Conflict Scale score >25) were present in 48% of surrogates. After adjusting for potential confounders, surrogates who had engaged in prior advance care planning conversations had significantly lower levels of decisional conflict than those who had not (mean score 3.3 points lower on the Decisional Conflict Scale; 95% confidence interval, 26.4 to 20.2; P = 0.03).Conclusions: Nearly half of surrogates for critically ill patients have moderate or high levels of decisional conflict. Prior advance care planning was associated with less decisional conflict. These results suggest that the scope of the benefit of advance care planning may extend beyond respecting patients' wishes to also ameliorating the burden on patients' loved ones who act as surrogates.

Decisional conflict in end‐of‐life cancer treatment among family surrogates: A cross‐sectional survey

“…In this regard, predictors of decisional conflict identified in this study would provide useful guidance to develop interventions for family surrogates' end-of-life cancer decision-making. The strongest predictor of decisional conflict was whether or not family surrogates knew the patients' wishes about end-of-life treatments, which is consistent with a previous study that showed surrogates who had engaged in prior advance care planning conversations showed less decisional conflict (Chiarchiaro et al, 2015). This finding showed that family surrogates' decisional conflict could be effectively alleviated when patients and their surrogates communicated patients' wishes about end-of-life treatment before facing the terminal stage of cancer.…”

“…It was also higher than that of surrogates in the USA who made endof-life decisions for critically ill patients in ICU (21.5; 25.5/100) (Chiarchiaro et al, 2015;Miller et al, 2016). While it has been a cultural tradition in Korean society for family members to take responsibility for making decisions on behalf of patients (Lee et al, 2013), our findings show that family members were unprepared to make end-oflife decisions, whereupon they experienced a severe level of conflict and stress in making decisions regarding end-of-life treatment for cancer.…”

“…Family surrogates' mean decisional conflict in this study (56/100) was almost two to three times higher than that of patients in Korea who made their own cancer treatment decisions regarding chemotherapy (29/100) (Kim, ) and surgery (18/56) (Yoon, Kim, & Park, ). It was also higher than that of surrogates in the USA who made end‐of‐life decisions for critically ill patients in ICU (21.5; 25.5/100) (Chiarchiaro et al, ; Miller et al, ). While it has been a cultural tradition in Korean society for family members to take responsibility for making decisions on behalf of patients (Lee et al, ), our findings show that family members were unprepared to make end‐of‐life decisions, whereupon they experienced a severe level of conflict and stress in making decisions regarding end‐of‐life treatment for cancer.…”

“…Decisional conflict, defined as a state of uncertainty about an appropriate course of action or decision, becomes greater when decisions involve end-of-life care (Miller, Morris, Files, Gower, & Young, 2016;O'Connor, 1995). However, to date, only a few studies have investigated decisional conflicts among surrogate decision-makers for patients with acute critical illnesses in intensive care units (Chiarchiaro, Buddadhumaruk, Arnold, & White, 2015;Miller et al, 2016), and little is known about those making end-of-life decisions for patients with terminal cancer.…”

How often are hospitalized patients and providers on the same page with regard to the patient's primary recovery goal for hospitalization?

“…On the other hand, when patient goals and priorities are clearly established, patients may have better outcomes . For example, earlier conversations about patient goals and priorities in serious illness can lead to realistic expectations of treatment, enhanced goal‐concordant care, improved quality of life, higher patient satisfaction, more and earlier hospice care, fewer hospitalizations, better patient and family coping, reduced burden of decision making for families, and improved bereavement outcomes …”