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

Recommendations

Numerous studies document significant variation in the approach to ICU decision-making, especially concerning complex clinical and ethical issues.[4,35–41] Although there is considerable variability between countries, studies suggest there is similar variation within countries or even between clinicians within a single hospital. Indeed, the perspective of individual clinicians may be the most important factor in decision-making.[4,35–41] A key goal of IP-SDM is to move from individual to team decisions for important clinical issues and when IP-SDM is likely to improve decisions, as well as patient, family, and clinician outcomes. As the systematic review yielded limited research, the following recommendations are based primarily on expert opinion and represent conditional recommendations. A conditional recommendation indicates uncertainty but still means that the intervention would be the appropriate action to take in most situations.[42,43]

Recommendation 1

"We recommend IP-SDM be defined as a collaborative process among clinicians that allows for team involvement in important clinical decisions, such as those pertaining to the goals and extent of treatment or other complex medical issues and taking into account the available evidence and combined expertise of clinicians involved as well as the patient's values, goals, and preferences."

Shared decision-making is defined as a process in which clinicians and patients (and/or surrogates) share information with both parties, taking steps to build consensus about the preferred treatment, where generally an agreement is reached on which treatment to implement.[44] Although addressing some of the same issues, IP-SDM is distinct and separate from shared decision-making with patients and their families. The latter describes "processes between the ICU teams and the patients and their families" and has been widely elaborated upon;[44–46] the former delineates the "processes within an ICU team" and has not been described in depth. There is often overlap in the process of shared-decision-making with patients and families and the process of IP-SDM, and there is also overlap in the composition of the groups involved in these two processes, yet it is helpful to separate them conceptually. Deliberations within teams rest on common medical understanding yet are often concerned with diverse assessments of the patients' status and treatment options; they benefit from diverse perspectives of the team members. During family meetings, the team should speak with "one voice" (within reason) and elicit how to best proceed in the patient's best interest. Discussions within the team will often influence discussions with patients and/or families and vice versa. However, in general, the ICU team should arrive at a decision about medically reasonable treatment options first, and these options should then be discussed with patients and/or family members, in principle using shared decision-making.[44,47]

Recommendation 2

"Regarding important clinical decisions, we recommend ICU clinicians consider engaging in an IP-SDM process in order to promote the most appropriate decisions."

Conceptually, decision-making can be executed on four different levels, going from individual decisions by one clinician to fully shared decision-making among a group of clinicians (Table 1).[48] These levels are intended to provide a conceptual guide to the process of decision-making, rather than serve as rigid or mutually exclusive approaches.

Clinical decisions are daily practice for ICU teams. Decisions are often appropriately made by individual clinicians (level 1) or after an exchange of information with other team members (level 2), including decisions to turn a patient, choosing antibiotics or whether to administer another fluid bolus. For slightly more nuanced issues, such as when to administer vasopressors, transfuse blood products or transfer a patient to acute care, involvement of other clinicians is common and depending on the circumstances, deliberation might be required (level 3).[49–52] Important care decisions with potentially far-reaching consequences for patients, families, and clinicians, such as the intensification or limitation of life-sustaining treatments, may warrant consideration of IP-SDM (level 4).[48,53] Whether a decision is "important" or "complex" may be a matter of debate among clinicians; this may be particularly true for decisions made at the higher levels of deliberation (level 3) versus shared decision-making (level 4), and we provide some examples in Table 2. The level of decision-making will largely depend on the complexity of the decision, patient circumstances, expertise of the team, and working relationships among team members.

When making important decisions, each clinician's level of involvement in IP-SDM may be influenced by many determinants, such as their individual judgment regarding the patient's prognosis, their experience and expertise, their hierarchical status in the ICU, and their personal and cultural values.[19,38,40,41,54,55] Importantly, a lack of recognition of value differences within the team in the context of complex clinical decisions can lead to unbalanced decisions and distress among clinicians.[12,14,16,22,33,56] If a decision is contrary to an individual team member's reasoned assessment or contrary to his/her professional values, then open deliberation and IP-SDM may be essential to ensure high-quality team functioning as well as individual clinician well-being.

Perhaps the most practical rationale for IP-SDM is that making use of the combined expertise and knowledge of all team members involved can lead to better-reasoned and more robust decisions. This, in turn, should improve outcomes for patients and their families. For example, studies demonstrate that when physicians and nurses agree about the prognosis for critically ill patients, their prognostication is significantly more accurate than sole prognostication of either a nurse or physician.[11,57,58] In addition, regular interprofessional team meetings, valuing the engagement of team members and promoting mutual respect, may help reduce moral distress and enhance resilience within the team.[29,31,34] The underlying principle is to transform individual clinicians into empowered and involved team members.

In many countries, the final authority and ensuing accountability for important clinical decisions ultimately lie with the attending physician or the department chair. However, the fact that ultimate responsibility belongs to one individual need not lessen the potential for IP-SDM, provided the clinician responsible believes the best decision was made and he or she can take responsibility for that decision.

Recommendation 3

"We recommend clinicians and hospitals implement strategies to accept and foster an ICU climate oriented toward interprofessional and interdisciplinary collaboration and IP-SDM."

Successful IP-SDM depends on interpersonal skills as well as a good ICU climate.[11,13,59–62] Organizational research has shown that work-units' climate and culture exert important influences on outcomes, such as unit performance.[63,64] Many diverse factors impact the climate-performance relationship in an ICU, especially adequacy of management, staffing, resources, effective leadership, and the safety and ethical climate.[11,61,65–70] Specifically, improving and to some degree formalizing the exchange of clinician assessments regarding the extent and goals of treatment might increase clinician satisfaction with care processes, decrease moral distress, and improve the ICU climate.[29–31] There is limited evidence that specific interventions to improve ICU work environment lead to improved organizational performance or patient outcomes.[71] Overall, however, skilled communication, true collaboration, and effective decision-making are recognized as imperative in establishing and sustaining healthy work environments—which in turn increase the likelihood that clinicians engage in IP-SDM.[11–14,21,25,29,31,60,66]

Consequently, we propose that ICU clinicians, and ICU physicians in particular, reflect on the types of situations in which they genuinely seek and incorporate the perspectives of the whole ICU team in decision-making. We acknowledge that IP-SDM may take significant time, and there may be circumstances where additional time spent by the ICU team could result in potential harms, related to either patient care or clinician stress. Assessment of potential harms related to IP-SDM should be incorporated into future research.

Recommendation 4

"We recommend clinicians consider incorporating basic principles of the VALUE TEAM-template as an explicit approach to respectful communication during IP-SDM."

Many clinical decisions depend on several clinicians, often from different disciplines and professions and with potentially conflicting approaches. Therefore, IP-SDM needs to rest on basic principles of respectful communication. Using a structured approach for such communication may reduce communication failures, improve information transfer, and increase the acceptability of treatment decisions, as well as job satisfaction, for the ICU team.

For communication between clinicians and families, use of a family-centered structured approach has been recommended. The VALUE-template, for example, focuses on valuing family statements and emotions, listening to the family, and understanding the patient as a person.[72,73] As a systematic approach to support IP-SDM within the ICU team, we recommend incorporating the "VALUE TEAM-template." Based on the VALUE-template,[72,73] it provides a guide for respectful communication, such as valuing all team members' statements and emotions, listening to each other and addressing diverse opinions, making use of each person's expertise and elaborating on patients' values and goals in order to arrive at decisions in the patient's best interest (Table 3).

Recommendation 5

"We recommend further studies be done to improve the quality of IP-SDM among ICU clinicians and evaluate the association between IP-SDM and outcomes for patients, family members, and clinicians."

As the recommendations above are based on limited evidence, further research is needed. Research is specifically needed to evaluate the current quality of IP-SDM among ICU clinicians regarding patient care in the ICU and to identify methods to improve and promote IP-SDM. In addition, there may be a role for IP-SDM in decisions about triage and admission to the ICU that warrant further exploration.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....