Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
Departments of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, MA, USA.
Crit Care. 2023 Oct 21;27(1):403. doi: 10.1186/s13054-023-04693-2.
Shared decision-making is a joint process where patients, or their surrogates, and clinicians make health choices based on evidence and preferences. We aimed to determine the extent and predictors of shared decision-making for goals-of-care discussions for critically ill neurological patients, which is crucial for patient-goal-concordant care but currently unknown.
We analyzed 72 audio-recorded routine clinician-family meetings during which goals-of-care were discussed from seven US hospitals. These occurred for 67 patients with 72 surrogates and 29 clinicians; one hospital provided 49/72 (68%) of the recordings. Using a previously validated 10-element shared decision-making instrument, we quantified the extent of shared decision-making in each meeting. We measured clinicians' and surrogates' characteristics and prognostic estimates for the patient's hospital survival and 6-month independent function using post-meeting questionnaires. We calculated clinician-family prognostic discordance, defined as ≥ 20% absolute difference between the clinician's and surrogate's estimates. We applied mixed-effects regression to identify independent associations with greater shared decision-making.
The median shared decision-making score was 7 (IQR 5-8). Only 6% of meetings contained all 10 shared decision-making elements. The most common elements were "discussing uncertainty"(89%) and "assessing family understanding"(86%); least frequent elements were "assessing the need for input from others"(36%) and "eliciting the context of the decision"(33%). Clinician-family prognostic discordance was present in 60% for hospital survival and 45% for 6-month independent function. Univariate analyses indicated associations between greater shared decision-making and younger clinician age, fewer years in practice, specialty (medical-surgical critical care > internal medicine > neurocritical care > other > trauma surgery), and higher clinician-family prognostic discordance for hospital survival. After adjustment, only higher clinician-family prognostic discordance for hospital survival remained independently associated with greater shared decision-making (p = 0.029).
Fewer than 1 in 10 goals-of-care clinician-family meetings for critically ill neurological patients contained all shared decision-making elements. Our findings highlight gaps in shared decision-making. Interventions promoting shared decision-making for high-stakes decisions in these patients may increase patient-value congruent care; future studies should also examine whether they will affect decision quality and surrogates' health outcomes.
共同决策是一个共同的过程，在这个过程中，患者或其代理人以及临床医生根据证据和偏好做出医疗选择。我们旨在确定在对危重症神经患者进行治疗目标讨论时共同决策的程度和预测因素，这对于患者目标一致的护理至关重要，但目前尚不清楚。
我们分析了来自美国 7 家医院的 72 个音频记录的常规临床医生-家属会议，在此期间讨论了治疗目标。这些会议涉及 67 名患者，72 名代理人和 29 名临床医生；一家医院提供了 72 次会议中的 49 次（68%）。使用以前验证的 10 项共同决策工具，我们量化了每次会议中共同决策的程度。我们使用会后问卷调查了临床医生和代理人对患者医院生存和 6 个月独立功能的特征和预后估计。我们计算了临床医生-家属之间的预后不一致，定义为临床医生和代理人的估计之间存在 ≥ 20%的绝对差异。我们应用混合效应回归来确定与更高程度的共同决策相关的独立因素。
中位数共同决策得分为 7（IQR 5-8）。只有 6%的会议包含了所有 10 个共同决策要素。最常见的要素是“讨论不确定性”（89%）和“评估家庭理解”（86%）；最不常见的要素是“评估是否需要他人的投入”（36%）和“引出决策的背景”（33%）。在医院生存方面，临床医生-家属之间的预后不一致性为 60%，在 6 个月的独立功能方面为 45%。单因素分析表明，共同决策程度更高与临床医生年龄较小、从业年限较短、专业（内科重症监护>内科>神经重症监护>其他>创伤外科）以及临床医生-家属之间对医院生存预后的差异更大有关。调整后，只有临床医生-家属之间对医院生存预后的差异更大与更高程度的共同决策独立相关（p=0.029）。
在对危重症神经患者进行治疗目标讨论的会议中，不到 10%的会议包含了所有共同决策要素。我们的发现突显了共同决策中的差距。在这些患者的高风险决策中促进共同决策的干预措施可能会增加患者价值一致的护理；未来的研究还应检验它们是否会影响决策质量和代理人的健康结果。
