Interprofessional Shared Decision-Making in the ICU

Table 1. Levels of Interprofessional Collaboration in Decisions (Modified From 55)
Name of Level	Definition	Example	Appropriate Use
Individual decision (level 1)	A clinical decision is made without involvement of another type of healthcare professional	The decision when to turn a patient during a shift	A clinical decision is made by one healthcare professional according to known practice guidelines or norms that are applied to a specific patient in an unambiguous clinical situation
		The choice of an antibiotic for a given patient with a known strain of bacterial infection
		While being suctioned by a nurse, a patient suddenly reverts to a fatal cardiac rhythm with very low blood pressure. The nurse immediately starts resuscitation while calling for a physician	In an emergency situation when other healthcare professionals are not available
Information exchange (level 2)	Relay of information from one healthcare professional to another, to be used by one healthcare professional for decision-making purposes	Relaying information about the patient's most current vital signs in a way that informs a unilateral decision to obtain an angiogram to rule out pulmonary embolism	Sharing of information that is obtained in the course of patient care
Information exchange (level 2)		A description of the clinical factors and physiologic underpinnings behind the decision not to give a patient a third fluid bolus	Explaining the reasoning behind clinical decisions that were made by other team members not involved in the decision-making process
Deliberation (level 3)	A two-way flow of information with some discussion, yet a decision is not made with shared decision-making	During medical rounds, there is a discussion of considerations as to why a specific patient should be treated with vasopressors and/or be given blood products. The attending physician then decides regarding these issues	The patient is assessed independently by different healthcare professionals who come to their own conclusions about patient care. These conclusions are then discussed. A final decision is made by one of the providers
Shared decision-making (level 4)	Each healthcare provider presents their information, a deliberation takes place, followed by a joint decision by participating providers	A patient with several chronic diseases is admitted to the ICU, suffers from many complications and presently is in multiple organ failure. The prognosis is very poor. After joint discussions among the ICU team, the staff members recommend to the family to change the treatment goal to comfort measures only	A complex patient care decision that involves many different patient care issues, where different healthcare providers can contribute their expertise to a decision. A discussion is held between the stakeholders, a joint decision is made and followed. The decision may involve ethical dilemmas, where no decision is totally correct

Table 2. Differentiating the Best Use of Deliberation (Level 3) From Shared Decision-Making (Level 4)
Decision	Circumstances That May Guide Best Level of Decision-Making	Potential Best Level of Decision-Making
Decision to withdraw life-sustaining treatment in a 62-yr-old man with metastatic lung cancer deteriorating after admission with pneumonia and sepsis	The attending physician had extensive conversations with the patient prior to the development of septic shock about his values, goals, and preferences and the patient was very clear on what treatments he would and would not accept	Deliberation but decision made by attending physician (level 3)
	The ICU nurse has had extensive conversations with the patient and family at the bedside and has important insights into the patient's values and goals	IP-SDM (level 4)
Decision to increase the inspiratory pressure of NIV for a frail 82-yr-old patient with a moderately effective breathing status and known chronic obstructive lung disease 3 d after extubation following a 10-d course of mechanical ventilation	The ICU nurse has extensive experience with this patient, with NIV, while the physician has less experience with the patient or with the patient's response to NIV	Deliberation but decision made by the ICU nurse (level 3)
	The ICU team (physician and nurse) have different but complementary expertise and experience with this patient and NIV, such	IP-SDM (level 4)
Decision to extubate a 72-yr-old patient with multiple chronic illnesses after 8 d of mechanical ventilation who has "marginal" weaning variables and a "marginal" spontaneous breathing trial	The ICU physician has been caring for the patient for all 8 d, knows the patient well, and believes this is the opportune time to extubate. This assessment is supported by the ICU team	Deliberation but decision made by attending physician (level 3)
	The ICU physician has been caring for the patient for 1 d, does not know the patient well yet, and needs the input of the ICU team to make a safe decision	IP-SDM (level 4)

IP-SDM = interprofessional shared decision-making, NIV = noninvasive ventilation.

Table 3. The VALUE TEAM-Template
V	Value the input from all of the members of the interprofessional team, including, among others, physicians, nurses, physiotherapists, clergy, psychologists, and ethicists;
A	Acknowledge emotions;
L	Listen to each other;
U	Understand the team-members as integral persons, including their commitments to patients and high-quality patient care;
E	Elicit the expert suggestions of team-members and make use of their specific expertise;
T	Tie the decision to the best evidence available;
E	Elaborate on the patient's values, goals, and preferences;
A	Address diverse opinions and seek consensus among team members; and
M	Make the best decision weighing reasonable medical options with the patient's goals and the quality of life he/she would want to achieve after their stay in the ICU

Authors and Disclosures

Andrej Michalsen, MD, MPH¹, Ann C. Long, MD, MS^2,3, Freda DeKeyser Ganz, PhD, RN⁴, Douglas B. White, MD, MAS⁵, Hanne I. Jensen, PhD, RN^6,7, Victoria Metaxa, MD, PhD⁸, Christiane S. Hartog, MD, PhD^9,10, Jos M. Latour, PhD, RN¹¹, Robert D. Truog, MD¹², Jozef Kesecioglu, MD, PhD¹³, Anna R. Mahn, RN¹⁰ and J. Randall Curtis, MD, MPH^2,3

¹Department of Anaesthesiology and Critical Care, Medizin Campus Bodensee – Tettnang Hospital, Tettnang, Germany.
²Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA.
³Cambia Palliative Care Center of Excellence, Harborview Medical Center, Department of Medicine, University of Washington, Seattle, WA.
⁴Hadassah Hebrew University School of Nursing, Jerusalem, Israel.
⁵Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
⁶Departments of Anaesthesiology and Intensive Care, Lillebaelt Hospital, Vejle, Denmark.
⁷Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
⁸Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom.
⁹Patient- and Family-Centered Care, Klinik Bavaria Kreischa, Kreischa, Germany.
¹⁰Department of Anesthesiology and Operative Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.
¹¹School of Nursing and Midwifery, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, United Kingdom.
¹²Center for Bioethics, Harvard, Medical School, as well as Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA.
¹³Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.

Dr. DeKeyser Ganz's institution received funding from the Israel Institute of Health Policy Research, and she received funding from the Israel Higher Education Commission. Dr. Metaxa received funding from European Society of Intensive Care Medicine. Dr. Truog received funding from Covance (Data Safety Monitoring Committee) and Sanofi (Data Safety Monitoring Committees). Dr. Kesecioglu reports receiving honorarium from Xenios A.G. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Interprofessional Shared Decision-Making in the ICU

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