Yale School of Medicine, Yale University, New Haven, CT, USA.
Yale New Haven Hospital, New Haven, CT, USA.
Neurocrit Care. 2021 Dec;35(3):714-722. doi: 10.1007/s12028-021-01211-6. Epub 2021 Apr 5.
There is a critical need to improve support for families making difficult shared decisions about patient care with clinicians in the neuroscience ICU (neuro-ICU). The aim of this study is to identify patient- and family-related factors associated with dissatisfaction with shared decision-making support among families of neuro-critically ill patients.
We conducted a retrospective observational cohort study using survey data that had been collected from a consecutive sample of family members of patients in the neuro-ICU (one family member per patient) at two US academic centers. Satisfaction with shared decision-making support on ICU discharge had been measured among family members using one specific Likert scale item on the Family Satisfaction in the ICU 24 survey, a validated survey instrument for families of patients in the ICU. We dichotomized top-box responses for this particular item as an outcome variable and identified available patient- and family-related covariates associated with dissatisfaction (i.e., less than complete satisfaction) via univariate and multivariate analyses.
Among 355 surveys, 180 (49.5%) of the surveys indicated dissatisfaction with support during decision-making. In a multivariate model, no preexisting characteristics of families or patients ascertainable on ICU admission were predictive of dissatisfaction. However, among family factors determined during the ICU course, experiencing three or fewer formal family meetings (odds ratio 1.93 [confidence interval 1.13-3.31]; p = 0.01) was significantly predictive of dissatisfaction with decisional support in this cohort with an average patient length of stay of 8.6 days (SD 8.4). There was also a trend toward a family's decision to keep a patient as full code, without treatment limitations, being predictive of dissatisfaction (odds ratio 1.80 [confidence interval 0.93-3.51]; p = 0.08).
Family dissatisfaction with neuro-ICU shared decision-making support is not necessarily predicted by any preexisting family or patient variables but appears to correlate with participating in fewer formal family meetings during ICU admission. Future studies to improve family satisfaction with neurocritical care decision-making support should have broad inclusion criteria for participants and should consider promoting frequency of family meetings as a core strategy.
在神经重症监护病房（神经 ICU）中，临床医生需要为正在做出艰难的患者护理共享决策的家庭提供支持，这方面的需求非常迫切。本研究的目的是确定与神经危重症患者家庭对共享决策支持不满相关的患者和家庭因素。
我们采用回顾性观察队列研究，使用了在美国两个学术中心的神经 ICU 连续样本中患者家属的调查数据。使用 ICU 24 家庭满意度量表中的一个特定 Likert 量表项目来衡量家属在 ICU 出院时对共享决策支持的满意度，该量表是 ICU 患者家属的验证性调查工具。我们将该特定项目的满分箱反应作为一个因变量，并通过单变量和多变量分析确定与不满（即不完全满意）相关的可用患者和家庭相关协变量。
在 355 份调查中，有 180 份（49.5%）表示对决策过程中的支持不满意。在多变量模型中，在 ICU 入院时可确定的家庭或患者的任何预先存在的特征都不能预测不满。然而，在 ICU 期间确定的家庭因素中，有 3 次或更少的正式家庭会议（优势比 1.93 [置信区间 1.13-3.31]；p=0.01）显著预测了该队列中具有平均 8.6 天（标准差 8.4）住院时间的决策支持不满。家庭决定保持患者无治疗限制的全码状态也有不满的趋势（优势比 1.80 [置信区间 0.93-3.51]；p=0.08）。
神经 ICU 共享决策支持的家庭不满不一定由任何预先存在的家庭或患者变量预测，而是似乎与在 ICU 入院期间参加的正式家庭会议较少相关。未来旨在改善神经危重症护理决策支持的家庭满意度的研究应将参与者的纳入标准放宽，并应考虑将增加家庭会议的频率作为核心策略。
