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

Materials and Methods

This is a project of the Section on Ethics of the European Society of Intensive Care Medicine which relies on a systematic review and normative analyses by experts to identify features of high-quality interprofessional communication and collaboration. The panel included ICU physicians and nurses as well as bioethicists. The panel conducted a systematic review of medical, nursing, critical care, and bioethical journals.

Clinical Question and Outcomes

The population-intervention-comparison-outcome (PICO) question, developed prior to the systematic review, was: "Should inter-professional shared decision-making versus no inter-professional shared decision-making be used in the care of critically ill patients?" The population is critically ill patients, the intervention is use of IP-SDM and the comparison is the absence of IP-SDM. Patient- and family-centered outcomes included: satisfaction with care, quality of communication, quality of dying, and psychologic symptoms. Clinician-centered outcomes included: interprofessional collaboration, interprofessional satisfaction with decision-making, moral distress, burnout, job satisfaction, and intent to leave.

Evidence Review and Evaluation

We developed search strategies using medical subject heading keywords and text words and used these to search MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane databases for relevant literature. The search strategies included terms related to decision-making, interprofessional, collaboration, and intensive care (Online Supplement, Supplemental Digital Content 1, http://links.lww.com/CCM/E723).

We used the following exclusion criteria: 1) no specific focus on IP-SDM in the ICU; 2) focus on patients less than 18 years old; 3) non-English language; and 4) use of qualitative methods only. The decision to exclude qualitative literature was made a priori, based on our goal to identify quantitative data to address the PICO question; qualitative papers were included in the normative analyses. We included articles from 1975 to October 2017.

All abstracts were screened by two of three authors; when decisions to include were in question, the third adjudicated. We assessed the quality of the evidence following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach,[28] based on the following criteria: risk of bias, precision, consistency, directness of the evidence, magnitude of effect, risk of publication bias, presence of dose-effect relationship and an assessment of the effect of residual confounding. Quality of the evidence was categorized into four levels: high, moderate, low, and very low. Meta-analysis was not performed due to heterogeneity in patient populations and outcomes.

The work of the panel was done through phone calls, e-mails, and four in-person meetings. Consensus for all recommendations was reached through deliberation; due to the small size of the panel, no formal voting process was used. Discordant minority positions were incorporated through deliberation and consensus. All decisions about GRADE were made by the authors who conducted the systematic review.

Definitions

For this review, "interprofessional" is defined as an interaction between clinicians of different professions (e.g., nurses, physicians, and other healthcare professionals working in the ICU), while "interdisciplinary" is defined as an interaction between clinicians of different disciplines within the same profession (e.g., internists, anesthesiologists, surgeons). "Important clinical decisions" refers to complex treatment decisions, often affected by patients', families', and clinicians' values, goals, and preferences, that have to be made by or for patients during their treatment in the ICU. Such decisions may concern complex medical or surgical treatments; such decisions may also concern the extent of treatment indicated or the limitation of life-sustaining treatments.

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