Values, preferences and goals identified during shared decision making between critically ill patients and their doctors

Abstract

Objective: Examine values, preferences and goals elicited by doctors following goals-of-care (GOC) discussions with critically ill patients who had life-limiting illnesses. Design: Descriptive qualitative study using four-stage latent content analysis. Setting: Tertiary intensive care unit (ICU) in South Western Victoria. Participants: Adults who had life-limiting illnesses and were admitted to the ICU with documented GOC, between October 2016 and July 2018. Intervention: The iValidate program, a shared decision-making clinical communication education and clinical support program, for all ICU registrars in August 2015. Main outcome measures: Matrix of themes and subthemes categorised into values, preferences and goals. Results: A total of 354 GOC forms were analysed from 218 patients who had life-limiting illnesses and were admitted to the ICU. In the categories of values, preferences and goals, four themes were identified: connectedness and relational autonomy, autonomy of decision maker, balancing quality and quantity of life, and physical comfort. The subthemes — relationships, sense of place, enjoyment of activities, independence, dignity, cognitive function, quality of life, longevity and physical comfort — provided a matrix of issues identified as important to patients. Relationship, place, independence and physical comfort statements were most frequently identified; longevity was least frequently identified. Conclusion: Our analysis of GOC discussions between medical staff and patients who had life-limiting illnesses and were admitted to the ICU, using a shared decision-making training and support program, revealed a framework of values, preferences and goals that could provide a structure to assist clinicians to engage in shared decision making.

Effect of communication skills training on documentation of shared decision-making for patients with life-limiting illness: An observational study in an intensive care unit

“…It is also possible an SDM approach led to patients choosing or experiencing longer periods of low-intensity hospital stay and reduced survival, through active decisions aligned to their values. From previous work, we identified patients prioritise other values such as dignity and independence over “living as long as possible” 4 , 35 , 36 ; therefore, reduced survival may not be considered a bad outcome by some patients. 2 This requires exploration through appropriately designed trial methodology.…”

Effect of a person‐centred goals‐of‐care form and clinical communication training on shared decision‐making and outcomes in an acute hospital: a prospective longitudinal interventional study

“…Hospital length of stay significantly decreased over the duration of the study, from a median of 7.5 days (IQR, [4][5][6][7][8][9][10][11][12][13][14] in Group 1 to 6 days (IQR, [3][4][5][6][7][8][9][10][11] in Group 6 when adjusted for age, gender and clinical trajectory (P = 0.005) (Fig. 3A).…”

“…3A). The time spent in hospital over the 90 days following index admission also significantly decreased from a median of 11 days (IQR, [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] in Group 1 to 7 days (IQR, 4-15) by Group 6 (P = 0.03), remaining significant after multivariable analysis (P = 0.01) (Fig. 3B).…”

“…8 In addition, there is a lack of validated tools to assess the components of SDM, including identification of patient goals, values and preferences and no clear evidence for interventions that may improve SDM. [9][10][11] The iValidate programme is a communication skills and support programme that aims to improve SDM for patients with LLI. The programme has been implemented in a tertiary healthcare institution since 2015.…”

“…Major barriers include inadequate communication skills training, clinician discomfort around having these conversations and a perceived lack of time 8 . In addition, there is a lack of validated tools to assess the components of SDM, including identification of patient goals, values and preferences and no clear evidence for interventions that may improve SDM 9–11 …”