Interprofessional Shared Decision-Making in the ICU

A Systematic Review and Recommendations From an Expert Panel

Andrej Michalsen, MD, MPH; Ann C. Long, MD, MS; Freda DeKeyser Ganz, PhD, RN; Douglas B. White, MD, MAS; Hanne I. Jensen, PhD, RN; Victoria Metaxa, MD, PhD; Christiane S. Hartog, MD, PhD; Jos M. Latour, PhD, RN; Robert D. Truog, MD; Jozef Kesecioglu, MD, PhD; Anna R. Mahn, RN; J. Randall Curtis, MD, MPH

Disclosures

Crit Care Med. 2019;47(9):1258-1266. 

In This Article

Abstract and Introduction

Abstract

Objectives: There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation.

Data Sources: We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making.

Study Selection: Three authors screened titles and abstracts in duplicate.

Data Synthesis: Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs.

Conclusions: Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.

Introduction

In many parts of the world, physicians, nurses, and other healthcare professionals working in ICUs, hereafter referred to as the ICU team, often treat patients autonomously and coordinate the input of other disciplines involved. With increasing independence, ICU teams have also become a prime source of information, guidance, and care for patients and their families. However, there are several important challenges to high-quality patient- and family-centered care in the ICU. First, despite significant advances in ICU care, approximately 15–30% of patients in ICUs die, often after complex decisions that further life-sustaining treatments are not indicated or not appropriate.[1–4] Second, improved ICU treatments result in more patients surviving with reduced quality of life. This entails tradeoffs for patients, families, and ICU teams that need to be addressed.[5,6] Third, healthcare expenditures for ICU care have risen dramatically, largely due to technological advancements and aging populations.[7,8] Finally, the humane and interpersonal aspects of care have not kept pace with technological advances.[9,10]

In the context of these challenges, a well-functioning ICU team that incorporates communication, collaboration, and shared decision-making is important for high-quality care. Unfortunately, successful teamwork in ICUs is often hampered by discord concerning prognostication, disagreement about indication for treatments, insufficient knowledge of patients' goals of care, and a lack of adequate communication, collaboration, and decision-making among team members. These deficiencies result in team conflicts, moral distress, burnout, poor patient care, and poor family support.[11–27] These deficiencies can be addressed through interprofessional communication and collaboration. Therefore, we developed this systematic review of existing empirical research, coupled with normative analyses by experts, to develop recommendations for interprofessional shared decision-making (IP-SDM) regarding important clinical decisions within the interprofessional ICU team.

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