Shared Decision Making in ICUs

Abstract

Objectives Shared decision-making (SDM) is endorsed by critical care organizations, however there remains confusion about what SDM is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define SDM, recommend when SDM should be used, identify the range of ethically acceptable decision-making models, and present important communication skills. Methods The American College of Critical Care Medicine (ACCM) and American Thoracic Society (ATS) Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of ACCM and ATS were included in the statement. Main Results Six recommendations were endorsed: 1) Definition: Shared decision-making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals, and preferences. 2) Clinicians should engage in a SDM process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their “default” approach a SDM process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies. Conclusions Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.

How acceptable is paternalism? A survey-based study of clinician and nonclinician opinions on paternalistic decision making

“…The four decision-making models—these three and the paternalistic model—were presented in random order (see Supplement B). A model with explicit shared decision making (Kon et al 2016) was not included as this was anticipated to have such high acceptability as to be uninformative, along with difficulties in succinctly describing all necessary elements of shared decision making within the space constraints of the survey.…”

Do Pediatric Patients Have a Right to Know?

“…In the absence of a court-ordered declaration of emancipation or other mechanism to warrant decisional autonomy-and therefore to be entitled to know all clinically pertinent information associated with the recommended treatment-minors must bend to the wishes of their authorized surrogates, usually their parent(s). While adolescents may be arguably unable to appreciate all of the benefits and burdens of a proposed course of action, they certainly have some appreciation, and engaging them in the decision-making process may be beneficial, although the data to support this are scant [6,7]. Nevertheless, physicians faced with the situation illustrated by this case can be torn between their beliefs that the child has a "right" to know about a probable side effect that could profoundly affect him in his adult life-and that could be mitigated by an anticipatory intervention such as sperm cryopreservation-and the desire of his parents to "protect" him.…”

Shared Decision Making in Neurocritical Care

“…It is defined as “a collaborative process involving both the physician and the patient or surrogate working together to make important decisions; it incorporates the beliefs, desires, and goals of patients and their families along with the expertise of the physician, and evidence based medicine to make the best health care decisions for the individual patient” 3–5 . SDM is commonly practiced using a “decision aid” (DA).…”

“…However, very few DAs exist in critical care 11,12 , despite the fact that choices in the intensive care unit (ICU), particularly the neuro-ICU, are often difficult and value-laden, and therefore may benefit from SDM 13 . Recently, a joint policy statement between the American College of Critical Care Medicine and the American Thoracic Society has highlighted the urgent need for SDM in critical care and made recommendations for the application of SDM in the ICU 3 .…”

“…One of the important goals of SDM is to clarify the patient’s values and preferences during the patient-physician conversation 1,3,8,18 . A patient’s goal might not always align with that of the physician.…”