Association between physicians’ beliefs and the option of comfort care for critically ill patients

Yael Schenker, Greer A. Tiver, Seo Yeon Hong, Douglas B. White
Original
Volume 38, Issue 10 / October , 2012

Pages 1607 - 1615

Abstract

Purpose

For critically ill patients at high risk of death, reasonable treatment options include attempts at life prolongation and treatment focused on comfort. Little is known about whether and how physicians present the option of comfort care to surrogates. This study assessed how comfort care is presented to surrogates and whether physicians’ beliefs are associated with whether comfort care is presented as an option.

Methods

Mixed-methods study of 72 audio-recorded family conferences about treatment decisions in five ICUs at two hospitals in San Francisco, California. One hundred sixty-nine family members and 54 physicians participated. Patients were at high risk of death or severe functional impairment. Transcripts of audio-recorded conferences were coded to identify whether physicians offered comfort care as an alternative to life-sustaining treatment and to characterize the stated risks and benefits. Physicians completed a questionnaire indicating the strength of their belief that life support should be foregone.

Results

The inpatient mortality rate was 72 %. Using a broad definition of comfort-oriented treatment, this option was presented in 56 % (95 % CI, 44–67 %) of conferences. In clustered multivariate models, the only independent predictor of offering comfort care as an option was the strength of the physician’s belief that life support should be foregone [OR 1.38 (1.14–1.66), p = 0.01].

Conclusions

Clinicians did not explicitly inform surrogates about the option of comfort-oriented treatment in roughly half of clinician-family meetings. Physicians who more strongly believe that the appropriate goal of care is life prolongation are less likely to inform surrogates about the option of comfort care.

Keywords

– Surrogate decision making – Patient centered care – Palliative care – Invasive life support

References

Wennberg JE, Fisher ES, Skinner JS (2002) Geography and the debate over Medicare reform. Health Aff (Millwood) Suppl Web Exclusives:W96-114
Thompson BT, Cox PN, Antonelli M, Carlet JM, Cassell J, Hill NS, Hinds CJ, Pimentel JM, Reinhart K, Thijs LG (2004) Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary. Crit Care Med 32:1781–1784. doi:00003246-200408000-00023
Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, Hinds C, Pimentel JM, Reinhart K, Thompson BT (2004) Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med 30:770–784. doi:10.1007/s00134-004-2241-5
- View ICM abstract
Davidson JE, Powers K, Hedayat KM, Tieszen M, Kon AA, Shepard E, Spuhler V, Todres ID, Levy M, Barr J, Ghandi R, Hirsch G, Armstrong D (2007) Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005. Crit Care Med 35:605–622
White DB, Engelberg RA, Wenrich MD, Lo B, Curtis JR (2007) Prognostication during physician-family discussions about limiting life support in intensive care units. Crit Care Med 35:442–448. doi:10.1097/01.CCM.0000254723.28270.14
White DB, Braddock CH 3rd, Bereknyei S, Curtis JR (2007) Toward shared decision making at the end of life in intensive care units: opportunities for improvement. Arch Intern Med 167:461–467. doi:10.1001/archinte.167.5.461
Breen CM, Abernethy AP, Abbott KH, Tulsky JA (2001) Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 16:283–289. doi:jgi00419
Abbott KH, Sago JG, Breen CM, Abernethy AP, Tulsky JA (2001) Families looking back: one year after discussion of withdrawal or withholding of life-sustaining support. Crit Care Med 29:197–201
Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, Canoui P, Le Gall JR, Schlemmer B (2000) Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 28:3044–3049
Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, Fassier T, Galliot R, Garrouste-Orgeas M, Goulenok C, Goldgran-Toledano D, Hayon J, Jourdain M, Kaidomar M, Laplace C, Larche J, Liotier J, Papazian L, Poisson C, Reignier J, Saidi F, Schlemmer B, Famirea study group (2005) Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 171:987–994. doi:10.1164/rccm.200409-1295OC
Wendler D, Rid A (2011) Systematic review: the effect on surrogates of making treatment decisions for others. Ann Intern Med 154:336–346
Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H (2010) Year in review in intensive care medicine 2009. Part III: mechanical ventilation, acute lung injury and respiratory distress syndrome, pediatrics, ethics, and miscellanea. Intensive Care Med 36:567–584. doi:10.1007/s00134-010-1781-0
- View ICM abstract
Fumis RR, Deheinzelin D (2009) Family members of critically ill cancer patients: assessing the symptoms of anxiety and depression. Intensive Care Med 35:899–902. doi:10.1007/s00134-009-1406-7
- View ICM abstract
Covinsky KE, Fuller JD, Yaffe K, Johnston CB, Hamel MB, Lynn J, Teno JM, Phillips RS (2000) Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The study to understand prognoses and preferences for outcomes and risks of treatments. J Am Geriatr Soc 48(5 Suppl):S187–S193
Barnato AE, Herndon MB, Anthony DL, Gallagher PM, Skinner JS, Bynum JP, Fisher ES (2007) Are regional variations in end-of-life care intensity explained by patient preferences?: a study of the US medicare population. Med Care 45:386–393
The SUPPORT Principal Investigators (1995) A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 274:1591–1598
Lynn J, Teno JM, Phillips RS, Wu AW, Desbiens N, Harrold J, Claessens MT, Wenger N, Kreling B, Connors AF Jr (1997) Perceptions by family members of the dying experience of older and seriously ill patients. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med 126:97–106
Wirtz VC, Cribb A, Barber N (2006) Patient-doctor decision-making about treatment within the consultation—a critical analysis of models. Soc Sci Med 62:116–124. doi:10.1016/j.socscimed.2005.05.017
Braddock CH 3rd, Edwards KA, Hasenberg NM, Laidley TL, Levinson W (1999) Informed decision making in outpatient practice: time to get back to basics. JAMA 282:2313–2320. doi:joc91394
Gattellari M, Voigt KJ, Butow PN, Tattersall MH (2002) When the treatment goal is not cure: are cancer patients equipped to make informed decisions? J Clin Oncol 20:503–513
Elwyn G, Edwards A, Wensing M, Hibbs R, Wilkinson C, Grol R (2001) Shared decision making observed in clinical practice: visual displays of communication sequence and patterns. J Eval Clin Pract 7:211–221
White DB, Malvar G, Karr J, Lo B, Curtis JR (2010) Expanding the paradigm of the physician’s role in surrogate decision-making: an empirically derived framework. Crit Care Med 38:743–750. doi:10.1097/CCM.0b013e3181c58842
University of California SFHRPP Committee on Human Research: surrogate consent. http://www.research.ucsf.edu/chr/guide/hsppGLsurrConsent.asp. Accessed November 20, 2011
Sandelowski M (2000) Whatever happened to qualitative description? Res Nurs Health 23:334–340
Sackett D, Guyatt G, Tugwell P (1991) Clinical epidemiology: a basic science for clinical medicine, 2nd edn. Little, Brown and Company, Boston
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829
Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H (2011) Year in review in Intensive Care Medicine 2010: II. Pneumonia and infections, cardiovascular and haemodynamics, organization, education, haematology, nutrition, ethics and miscellanea. Intensive Care Med 37:196–213. doi:10.1007/s00134-010-2123-y
- View ICM abstract
Bertolini G, Boffelli S, Malacarne P, Peta M, Marchesi M, Barbisan C, Tomelleri S, Spada S, Satolli R, Gridelli B, Lizzola I, Mazzon D (2010) End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units. Intensive Care Med 36:1495–1504. doi:10.1007/s00134-010-1910-9
- View ICM abstract
Charles C, Gafni A, Whelan T (1999) Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 49:651–661. doi:S0277953699001458
Elwyn G, O’Connor A, Stacey D, Volk R, Edwards A, Coulter A, Thomson R, Barratt A, Barry M, Bernstein S, Butow P, Clarke A, Entwistle V, Feldman-Stewart D, Holmes-Rovner M, Llewellyn-Thomas H, Moumjid N, Mulley A, Ruland C, Sepucha K, Sykes A, Whelan T (2006) Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. BMJ 333:417
Cook DJ, Guyatt GH, Jaeschke R, Reeve J, Spanier A, King D, Molloy DW, Willan A, Streiner DL (1995) Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill. J Am Med Assoc 273:703–708
Pearlman RA, Inui TS, Carter WB (1982) Variability in physician bioethical decision-making. Ann Intern Med 97:420–425
Garland AC, Alfred F Jr (2007) Physicians’ influence over decisions to forego life support. J Palliat Med 10:1298–1305. doi:10.1089/jpm.2007.0061
Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA (2000) Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 284:2476–2482
Levy CR, Ely EW, Payne K, Engelberg RA, Patrick DL, Curtis JR (2005) Quality of dying and death in two medical ICUs: perceptions of family and clinicians. Chest 127:1775–1783. doi:10.1378/chest.127.5.1775
Russ AJ, Kaufman SR (2005) Family perceptions of prognosis, silence, and the “suddenness” of death. Cult Med Psychiatry 29:103–123
Lind R, Lorem GF, Nortvedt P, Hevroy O (2011) Family members’ experiences of “wait and see” as a communication strategy in end-of-life decisions. Intensive Care Med 37:1143–1150. doi:10.1007/s00134-011-2253-x
- View ICM abstract
Barry LC, Kasl SV, Prigerson HG (2002) Psychiatric disorders among bereaved persons: the role of perceived circumstances of death and preparedness for death. Am J Geriatr Psychiatry 10:447–457
Burt RA (2002) Death is that man taking names. University of California Press, Berkeley
Steinhauser KE, Clipp EC, McNeilly M, Christakis NA, McIntyre LM, Tulsky JA (2000) In search of a good death: observations of patients, families, and providers. Ann Intern Med 132:825–832
The AM, Hak T, Koeter G, van Der Wal G (2000) Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ 321:1376–1381
Curtis JR, Engelberg RA, Wenrich MD, Shannon SE, Treece PD, Rubenfeld GD (2005) Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med 171:844–849

Sign In

Username Password Remember me on this computer

Connect with ICM

Follow ICM on Twitter Join the ICM LinkedIn Group Like ICM on Facebook