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Decision aid does not alter surrogate choices for patients with mechanical ventilation
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A personalized web-based decision aid for surrogates of patients receiving prolonged mechanical ventilation did not improve prognostic concordance between clinicians and surrogates, change surrogate-decisions about treatment goals or alter clinical outcomes, according to a study published in the Annals of Internal Medicine.
“There had been a hope that decision aids would reduce the use of high cost, potentially lower-yield therapies,” Christopher E. Cox, MD, of Duke University, told Healio Primary Care Today. “In fact, the Affordable Care Act specifically pushed for the broader clinical use of decision aids. However, we found that it may be much harder to apply decision aids in an acute setting, where timelines are short and stress levels are high.”
Researchers conducted a patient-level, randomized, clinical trial of 277 patients receiving mechanical ventilation, 416 surrogates and 427 clinicians from 13 medical and surgical ICUs at five hospitals between December 2012 and January 2017.
Patients and their surrogates were randomly assigned 1:1 to either the intervention or control group. The intervention consisted of a web-based decision aid that defined prolonged mechanical ventilation, provided personalized 1-year prognostic estimates, explained treatment options and clarified patient values. The decision aid then summarized each surrogate’s responses for clinicians to review. Participants in the intervention group also had a family meeting where clinicians discussed the content of the decision aid summary document.
Surrogates in the control group received only a family meeting.
The primary outcome of the study was improved concordance on 1-year survival estimates, which was measured as the difference between the surrogate’s response and that of the treating physician to the question, “What percent chance do you think the patient/your loved one has of being alive 1 year from now if the current treatment plan is continued?” Scores ranged from 0 to 100 percentage points with higher values indicating greater discordance.
Researchers found that surrogates in both the intervention and control group had similar concordance improvement (mean difference in score change from baseline, –1.7 percentage points; 95% CI, –8.3 to 4.8) and similar estimates of patients’ 1-year prognoses (median, 86% vs 92.5%; P = .23).
Both groups 1-year survival estimates were more optimistic than results of a validated prediction model (median, 56%) and physician estimates (median, 50%).
Furthermore, 43% of intervention surrogates preferred a treatment option that was more aggressive than their reports of how the patient wished to be treated.
Finally, researchers found that intervention surrogates had greater reduction in decisional conflict than control surrogates (mean difference in change from baseline, 0.4; 95% CI, 0-0.7; P = 0.41), though there was no difference in psychological distress or quality of communication between the groups and no difference in patient length of stay or 6-month mortality.
“These are extremely difficult situations in which family members are stressed, scared, sleep-deprived, and often confused by the numerous clinicians and complex life support technologies,” Cox said. “The quality of ICU decision making is suboptimal, and we need to continue to try to find ways to better support patients and families. Thinking of ways to better integrate decision aids with added emotional support is a likely next step.”
In a related editorial, Aaron M. Tannenbaum, MD, and Scott D. Halpern, MD, PhD, both of the Perelman School of Medicine at the University of Pennsylvania, wrote: “Although we agree with Cox and colleagues that surrogates' emotions may have blunted the effect of the decision aid, we also posit that interventions that merely enhance knowledge and induce deliberation may never promote better surrogate decision making. What may work better? Future research will be needed to answer this question. However, informed by insights from this meticulously conducted trial, we might predict that had clinicians reviewed surrogates' responses with them, they may have been able to access surrogates' beliefs, attend to their emotions, and unpack their overly optimistic expectations and the sources of their ensuing preferences.” – by Melissa J. Webb
For more information:
Christopher E. Cox, MD, can be reached at christopher.cox@duke.edu.
Disclosures: Cox reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Tannenbaum reports receiving grants from NIH.