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

Results

We screened 1,162 abstracts, of which 1,119 were excluded, leaving 43 for full review (Figure 1). Of these 43, 39 were excluded, mainly due to lack of specific focus on IP-SDM, leaving four articles for analysis (Table e1, Supplemental Digital Content 1, http://links.lww.com/CCM/E723).[29–32]

Figure 1.

Flow diagram of article inclusion. CINAHL = Cumulative Index to Nursing and Allied Health Literature, IP-SDM = interprofessional shared decision-making.

In a cross-sectional study of 90 ICU clinicians in one ICU in the United States, Baggs and Schmitt[32] found a positive correlation between the degree of collaboration among staff and satisfaction with clinical decisions regarding the extent ("aggressiveness") of treatment (for nurses, r = 0.70; for residents, r = 0.50). These results were corroborated by subsequent studies, especially regarding the relationship between insufficient participation in decision-making and dissatisfaction among nurses.[16,22,24,25,27,33]

In an observational study of 152 clinicians from two Danish ICUs, Jensen et al[31] compared end-of-life care before and after implementation of hospital guidelines articulating the importance of interdisciplinary meetings to make decisions regarding extent of treatment. For patients who died after withdrawal of life-sustaining therapies, ICU length of stay did not differ significantly after the intervention (3.1 vs 1.7 d; p = 0.06). However, median time from admission to first consideration of extent of therapy was lower following guideline implementation (1.1 vs 0.4 d; p = 0.03), as was median time from admission to a withdrawal decision (3.1 vs 1.1 d; p = 0.02). Furthermore, healthcare professionals' perception of quality of care was better post implementation. These findings suggest that regular interdisciplinary meetings related to complex treatment decisions reduce patient suffering and dissatisfaction among clinicians.

In a cross-sectional study of 566 Italian ICU nurses, Karanikola et al[30] explored the level of moral distress and its association with determinants of their work. The investigators found a negative correlation between frequency and severity of moral distress and nurse-physician collaboration (r = –0.169; p < 0.0001 and r = –0.215; p < 0.0001, respectively) as well as a positive correlation between nurse-physician collaboration and work satisfaction (r = 0.276; p < 0.001). This study supports the importance of interdisciplinary collaboration.[13,22,34]

In an observational study of 50 ICU clinicians in one Belgian ICU, Van den Bulcke et al[29] evaluated an intervention designed to improve ICU teamwork. The intervention included structured weekly interprofessional meetings and in-depth case discussions. Study participants reported significant improvement in perceived "organizational factors" and "care processes" (p < 0.001 for both items, using a validated instrument), suggesting regular interprofessional meetings facilitate timely decision-making about the extent of treatment.

Overall, the quality of the evidence was very low (Table e2, Supplemental Digital Content 2, http://links.lww.com/CCM/E724; and Table e3, Supplemental Digital Content 3, http://links.lww.com/CCM/E725).

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