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Most clinician-family conferences do not consider patient values, preferences

Most conferences between clinicians and family members about prognosis and goals of care for patients in the ICU lack crucial communication about values and preferences, according to research published in JAMA Internal Medicine.

“Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating ICU patients’ values and preferences into treatment decisions,” Leslie P. Scheunemann, MD, MPH, from the division of geriatric medicine and gerontology at University of Pittsburgh, and colleagues wrote.

Scheunemann and colleagues performed a secondary analysis of a prospective, multicenter cohort study to evaluate how often clinicians and surrogates in ICUs include critically ill patients’ previously expressed values and preferences into treatment plans.

The researchers reviewed transcripts of audio recorded conversations in which clinicians and surrogates exchanged information about patients’ treatment preferences and health-related values and determined how that information was applied in deliberation and treatment planning. They included 244 conversations about 249 incapacitated, critically ill adults (54.9% men; mean age, 58.2 years) who lacked decision-making capacity, were diagnosed with acute respiratory distress syndrome and had a predicted in-hospital mortality of 50% or more.

The researchers found that 25.8% of the conferences about care goal decisions did not contain any information exchange or deliberation about patients’ values and preferences. In 68.4% of conversations, clinicians and surrogates discussed patients’ values and preferences. In 44.3% of conversations, clinicians and surrogates discussed how to apply the patients’ values to the decision.

In 35.7% or less of the conversations, important end-of-life considerations, including physical, cognitive, and social functioning or spirituality were discussed. Only 8.2% of treatment recommendations were based on patients’ values and preferences.

“Without a shared understanding of patients’ values and preferences ... clinicians and families are likely to struggle to agree on a patient-centered treatment strategy,” Scheunemann and colleagues concluded. “This situation merits development of interventions to better prepare surrogates to represent patients’ values and preferences in ICU family conferences and train clinicians to facilitate these conversations. For now, we recommend that clinicians should ask questions and recommend treatment based on their best understanding of how patients would feel about their expected lifestyle and functioning after critical illness.” – by Alaina Tedesco

Disclosures: Scheunemann reports grants from the National Institute on Aging and grants from National Heart, Lung, and Blood Institute. Please see study for all other authors’ relevant financial disclosures.