How to Reach Agreement Between Clinicians and Families on ICU Care

When there are disagreements about ICU care, methods to achieve resolution include communicating prognosis and offering treatment options.

For patients in intensive care units (ICUs), there is disagreement between clinicians and patients and their surrogates in about one-third of cases, recent research indicates.

Among patients and their surrogates, perceptions of inappropriate treatment are linked with lower satisfaction and decreased trust in the care team, the research found. For ICU clinicians and nurses, earlier research found delivery of treatment that caregivers perceived as inappropriate increased the likelihood of burnout.

Examining disagreements between clinicians and patients and their surrogates is crucial to addressing the decision-making challenge, researchers wrote last month in the journal CHEST. "It is important to understand the nature of perceived inappropriate treatment in order to be able to implement measures to ameliorate disagreements about treatment intensity in critically ill patients."

The recent research—which is based on surveys of more than 1,300 patients, surrogates, physicians, and nurses—features several key findings:

• For 26% of ICU patients, there was disagreement between clinicians and patients and surrogates over provision of too much care
   
• For 10% of ICU patients, there was disagreement between clinicians and patients and surrogates over provision of too little care
   
• For 55% of patients and surrogates, a perception of inappropriate treatment was associated with moderate or high distress
   
• For 35% of clinicians and nurses, a perception of inappropriate treatment was associated with moderate or high distress

The study data also indicated that some of the discordant perceptions about the appropriateness of care were based on prognostic factors, the researchers wrote. "Since patients and surrogates are often unaware that their prognostic estimates differ from those of physicians, these findings highlight the importance of improving prognostic communication and understanding."

Bridging the perception gap
 

While some level of disagreement over ICU care is unavoidable, the magnitude of disagreement found in the recent research can be reduced, the lead author of the study told HealthLeaders.

"For there to be more agreement about whether a trial of life support is the right thing to do for a particular patient, we need to help families accurately understand the available treatment pathways and their outcomes. And we need to help physicians be able to accurately understand the values and preferences of the patients," said Michael Wilson, MD, a critical care specialist in the Department of Pulmonary Medicine at Mayo Clinic in Rochester, Minnesota.

There are two primary steps to improve prognostic communication and understanding, he said.

"The first way to improve communication of prognosis is to actually do it. A majority of patients and families desire prognostic information; but for a significant proportion of patients, doctors don't discuss prognosis."

Second, uncertainty regarding prognostic information should be acknowledged, Wilson said.

"In large studies, doctors are no better than a coin toss at predicting whether or not patients will survive and leave the hospital. In addition, there is high variability in physician predictions—two doctors with the exact same patient and circumstances may come up with vastly different conclusions about whether the patient will survive and what their life will be like if they do survive. When I talk about prognosis with families, I talk about the best case scenario, the worst case scenario, and the most likely scenario. This is a way that acknowledges a range of possible outcomes, but still allows me to give my professional opinion about what I think will happen."

Reaching agreement
 

There are four ways to improve collaborative decision making between clinicians and patients and their surrogates, Wilson said.

• More effort should be devoted to preparing families before they have decision-making conversations with their medical teams.
   
• Clinicians should clearly distinguish decision pathways and present those options to patients and their surrogates. Options focused solely on comfort should be discussed.
   
• Clinicians should make a recommendation about what treatment pathway is best for the patient. This recommendation should be based on the clinician's understanding of both the medical facts as well as the clinician's understanding of who the patient is as a human being—his or her values, preferences, quality of life, and goals. "We cannot abandon patients and families to make these decisions alone," he said.
   
• Decision making should be tailored to the individual patient, family, and situation. Some families want every detail. Other families only want the big picture. Some families want to participate in decision making. Other families want to follow the physician's lead. Sometimes, families are so completely exhausted and stressed that they do not know what to do, and they just need more time and space.