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Shared Decision Making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement

Kon, Alexander A. MD, FCCM1,2; Davidson, Judy E. DNP, RN, FCCM3; Morrison, Wynne MD, MBE, FCCM4; Danis, Marion MD, FCCM5; White, Douglas B. MD, MAS6

doi: 10.1097/CCM.0000000000001396
Special Article

Objectives: Shared decision making is endorsed by critical care organizations; however, there remains confusion about what shared decision making is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define shared decision making, recommend when shared decision making should be used, identify the range of ethically acceptable decision-making models, and present important communication skills.

Design: The American College of Critical Care Medicine and American Thoracic Society Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of American College of Critical Care Medicine and American Thoracic Society were included in the statement.

Main Results: Six recommendations were endorsed: 1) Definition: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals, and preferences. 2) Clinicians should engage in a shared decision making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their “default” approach a shared decision making process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable, including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies.

Conclusions: Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.

1Pediatric Critical Care Medicine, Naval Medical Center San Diego, San Diego, CA.

2Department of Pediatrics, University of California San Diego School of Medicine, San Diego, CA.

3University of California Health System, San Diego, CA.

4Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, PA.

5Department of Bioethics, National Institutes of Health, Bethesda, MD.

6Program on Ethics and Decision Making in Critical Illness and Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

The views expressed in this article represent the official position of the American College of Critical Care Medicine, the Society of Critical Care Medicine, and the American Thoracic Society. These views do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, National Institutes of Health, Department of Veterans Affairs, Food and Drug Administration, or the U.S. Government.

Dr. Kon is the President-elect of the American Society for Bioethics and Humanities, an Associate Editor for AJOB Empirical Research Bioethics, and receives funding from the Greenwall Foundation’s Faculty Scholars in Bioethics program. Dr. Davidson holds a business license for a private education company; however, she has earned no income related to the topic presented in this statement. She also provides research-related volunteer services to American Association of Critical Care Nurses and Sima Theta Tau International on topics not related to those presented in this statement. Dr. Morrison is a member of a data monitoring committee for Glaxo Smith Klein on research not related to the topics covered in this statement, is a speaker and committee member of the American Society for Bioethics and Humanities, and is an editorial board member for the American Academy of Pediatrics. Dr. Danis has professional relationships with the American Society for Bioethics and Humanities and the Society of General Internal Medicine not directly related to the topics covered in this statement. Dr. White receives grant funding from the Greenwall Foundation and from the Moore Foundation. Potential conflicts of interest for members of the writing group were reviewed based on American College of Critical Care Medicine standard operating procedure. No potential conflicts relating to the content of this statement were identified.

Dr. Kon received funding from the Greenwall Foundation Faculty Scholars in Bioethics (The Foundation pays travel expenses for semiannual scholars’ meeting and from American Society for Bioethics and Humanities. Dr. Kon was a member of the Board of Directors and was therefore reimbursed for travel expenses to Board meetings) and he disclosed government work. Dr. Morrison received support from several grand rounds presentations at other academic institutions with honoraria and received funding from the On Data Monitoring Committee for Glaxo-Smith-Klein (paid consultant position, but no payment yet received). Dr. Danis received support for article research from the National Institutes of Health (NIH), disclosed government work, and is an employee of the NIH (Her work on this project has been supported by the intramural program of the NIH. The views expressed in this paper are not necessarily a reflection of the policies of the NIH or the US Dept of Health and Human Service). Dr. White received support for article research from the NIH. Dr. Davidson disclosed that she does not have any potential conflicts of interest.

For information regarding this article, E-mail: kon.sandiego@gmail.com

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