Secondary Logo

Institutional members access full text with Ovid®

Disagreement Between Clinicians and Score in Decision-Making Capacity of Critically Ill Patients*

Bertrand, Pierre-Marie, MD1; Pereira, Bruno, PhD2; Adda, Mireille, MSc1; Timsit, Jean-François, MD, PhD3; Wolff, Michel, MD, PhD4; Hilbert, Gilles, MD, PhD5; Gruson, Didier, MD, PhD5; Garrouste-Orgeas, Maïté, MD, PhD6; Argaud, Laurent, MD, PhD7; Constantin, Jean-Michel, MD, PhD8; Chabanne, Russel, MD8; Quenot, Jean-Pierre, MD, PhD9; Bohe, Julien, MD, PhD10; Guerin, Claude, MD, PhD11; Papazian, Laurent, MD, PhD12; Jonquet, Olivier, MD, PhD13; Klouche, Kada, MD, PhD13; Delahaye, Arnaud, MD14; Riu, Beatrice, MD15; Zieleskiewicz, Laurent, MD16; Darmon, Michaël, MD, PhD17; Azoulay, Elie, MD, PhD18; Souweine, Bertrand, MD, PhD1,19; Lautrette, Alexandre, MD, PhD1,19

doi: 10.1097/CCM.0000000000003550
Clinical Investigations
Buy
SDC

Objectives: To compare the assessment of decision-making capacity of ICU patients by attending clinicians (physicians, nurses, and residents) with a capacity score measured by the Mini-Mental Status Examination, completed by Aid to Capacity Evaluation if necessary. The primary outcome was agreement between physicians’ assessments and the score. Secondary outcomes were agreement between nurses’ or residents’ assessments and the score and identification of factors associated with disagreement.

Design: A 1-day prevalence study.

Setting: Nineteen ICUs in France.

Subjects: All patients hospitalized in the ICU on the study day and the attending clinicians.

Interventions: The decision-making capacity of patients was assessed by the attending clinicians and independently by an observer using the score.

Measurements and Main Results: A total of 206 patients were assessed by 213 attending clinicians (57 physicians, 97 nurses, and 59 residents). Physicians designated more patients as having decision-making capacity (n = 92/206 [45%]) than score (n = 34/206 [17%]; absolute difference 28% [95% CI, 20–37%]; p = 0.001). There was a high disagreement between assessments of all clinicians and score (Kappa coefficient 0.39 [95% CI, 0.29–0.50] for physicians; 0.39 [95% CI, 0.27–0.52] for nurses; and 0.46 [95% CI, 0.35–0.58] for residents). The main factor associated with disagreement was a Glasgow Coma Scale score between 10 and 15 (odds ratio, 2.92 [1.18–7.19], p = 0.02 for physicians; 4.97 [1.50–16.45], p = 0.01 for nurses; and 3.39 [1.12–10.29], p = 0.03 for residents) without differentiating between the Glasgow Coma Scale scores from 10 to 15.

Conclusions: The decision-making capacity of ICU patients was largely overestimated by all attending clinicians as compared with a score. The main factor associated with disagreement was a Glasgow Coma Scale score between 10 and 15, suggesting that clinicians confused consciousness with decision-making capacity.

1Intensive Care Unit, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.

2Biostatistics Unit, Delegation à la Recherche Clinique (DRCI), University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.

3Intensive Care Unit, Albert Michallon Hospital, University Hospital of Grenoble, Grenoble, France.

4Intensive Care Unit, Bichat-Claude Bernard Hospital, Assistance Publique - Hopitaux de Paris, Paris, France.

5Intensive Care Unit, Pellegrin-Tripode Hospital, University Hospital of Bordeaux, Bordeaux, France.

6Intensive Care Unit, Saint-Joseph Hospital, Paris, France.

7Intensive Care Unit, Edouard Herriot Hospital, University Hospital of Lyon, Lyon, France.

8Intensive Care Unit, Department of Anaesthesiology, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.

9Intensive Care Unit, Bocage Central Hospital, University Hospital of Dijon, Dijon, France.

10Intensive Care Unit, Hospices Civils Hospital, University Hospital of Lyon, Lyon, France.

11Intensive Care Unit, Croix Rousse Hospital, University Hospital of Lyon, Lyon, France.

12Intensive Care Unit, Nord Teaching Hospital, University Hospital of Aix-Marseille, Marseille, France.

13Intensive Care Unit, Lapeyronie Hospital, University Hospital of Montpellier, Montpellier, France.

14Intensive Care Unit, Rodez Hospital, Rodez, France.

15Intensive Care Unit, Purpan Hospital, University Hospital of Toulouse, Toulouse, France.

16Intensive Care Unit, Department of Anaesthesiology, Nord Teaching Hospital, University Hospital of Aix-Marseille, Marseille, France.

17Intensive Care Unit, Nord Teaching Hospital, University Hospital of Saint-Etienne, Saint-Etienne, France.

18Intensive Care Unit, Saint-Louis Hospital, Assistance Publique - Hopitaux de Paris, Paris, France.

19LMGE «Laboratoire Micro-organismes: Génome et Environnement», UMR CNRS 6023, Clermont-Auvergne University, Clermont-Ferrand, France.

*See also p. 471.

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 website (http://journals.lww.com/ccmjournal).

Supported, in part, by the Gabriel Montpied Teaching Hospital.

Dr. Wolff’s institution received funding from Pfizer. Dr. Azoulay’s institution received funding from Fisher & Paykel, Pfizer, Alexion, Gilead, and Jazz Pharma, and he received funding from lecturing for Baxter, Gilead, Astellas, and Alexion. Dr. Lautrette received support for article research from Gabriel Montpied Teaching Hospital (France). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: alautrette@chu-clermontferrand.fr

Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.