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Development and pilot testing of a decision aid for surrogates of patients with prolonged mechanical ventilation*

Cox, Christopher E. MD, MPH; Lewis, Carmen L. MD, MPH; Hanson, Laura C. MD, MPH; Hough, Catherine L. MD, MSc; Kahn, Jeremy M. MD, MSc; White, Douglas B. MD, MSc; Song, Mi-Kyung RN, PhD; Tulsky, James A. MD; Carson, Shannon S. MD

doi: 10.1097/CCM.0b013e3182536a63
Clinical Investigations

Objective: Shared decision making is inadequate in intensive care units. Decision aids can improve decision making quality, though their role in an intensive care units setting is unclear. We aimed to develop and pilot test a decision aid for shared decision makers of patients undergoing prolonged mechanical ventilation.

Setting: Intensive care units at three medical centers.

Subjects: Fifty-three surrogate decision makers and 58 physicians.

Design and Interventions: We developed the decision aid using defined methodological guidelines. After an iterative revision process, formative cognitive testing was performed among surrogate–physician dyads. Next, we compared the decision aid to usual care control in a prospective, before/after design study.

Measurements and Main Results: Primary outcomes were physician–surrogate discordance for expected patient survival, comprehension of relevant medical information, and the quality of communication. Compared to control, the intervention group had lower surrogate–physician discordance (7 [10] vs. 43 [21]), greater comprehension (11.4 [0.7] vs. 6.1 [3.7]), and improved quality of communication (8.7 [1.3] vs. 8.4 [1.3]) (all p < .05) post-intervention. Hospital costs were lower in the intervention group ($110,609 vs. $178,618; p = .044); mortality did not differ by group (38% vs. 50%, p = .95). Ninety-four percent of the surrogates and 100% of the physicians reported that the decision aid was useful in decision making.

Conclusion: We developed a prolonged mechanical ventilation decision aid that is feasible, acceptable, and associated with both improved decision-making quality and less resource utilization. Further evaluation using a randomized controlled trial design is required to evaluate the decision aid’s effect on long-term patient and surrogate outcomes.

From the Department of Medicine (CEC), Division of Pulmonary and Critical Care Medicine, Duke University, Durham, NC; Department of Medicine (CLL), Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill, NC; Department of Medicine (LCH), Division of Geriatric Medicine, Palliative Care Program, University of North Carolina, Chapel Hill, NC; Department of Medicine (CLH), Division of Pulmonary and Critical Care; University of Washington, Seattle, WA; Department of Critical Care (JMK, DBW), University of Pittsburgh, Pittsburgh, PA; Program on Ethics and Decision Making in Critical Illness (DBW), University of Pittsburgh, Pittsburgh, PA; School of Nursing (M-KS), University of North Carolina, Chapel Hill, NC; Department of Medicine (JAT), Center for Palliative Care, Duke University, Durham, NC; Center for Health Services Research in Primary Care (JAT), VA Medical Center, Durham, NC; Department of Medicine (SSC), Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC.

*See also. p. 2505.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://journals.lww.com/ccmjournal).

Supported by National Institutes of Health awards K23 HL081048 (CEC), K07 CA104128 (CLL), K23 HL082650 (JMK), K23 AG032875 (DBW), and K23 HL067068 (SSC).

Dr. Cox consulted for RTI International. The remaining authors have not disclosed any potential conflicts of interest.

For more information regarding this article, E-mail: christopher.cox@duke.edu

© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins