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Confidence in life-support decisions in the intensive care unit

A survey of healthcare workers

Walter, Stephen D. PhD; Cook, Deborah J. MD, FRCP, MSc; Guyatt, Gordon H. MD, FRCP, MSc; Spanier, Allan MD, FRCP; Jaeschke, Roman MD, FRCP, MSc; Todd, Thomas R. J. MD, FRCSC; Streiner, David L. PhD

Clinical Investigations

Objective To examine the relationship between intensive care unit (ICU) healthcare workers' confidence and their decision to withdraw life support.

Design Cross-sectional survey of Canadian intensivists, ICU housestaff, and bedside nurses. Respondents chose the level of care (from comfort measures only to full aggressive care) for 12 patients described in clinical scenarios, and rated their confidence in their decisions.

Setting Thirty-seven Canadian university-affiliated hospitals.

Patients None.

Interventions We used discrete data analysis models to examine the association between the chosen level of care, confidence in the decisions, the clinical scenario, and healthcare worker group.

Measurements and Main Results The response rate was 1,361 (76%)/1,795; for this analysis, we used data from 1,306 respondents with completed questionnaires. Responses for each scenario varied widely among respondents. The level of care chosen was dependent on the scenario, the healthcare worker group, and the confidence with which the decisions were made (p < .001 for each). Intensivists were less aggressive than the ICU nurses, who were less aggressive than the housestaff, but the magnitude of effect was small. Overall, respondents were very confident about their decisions 34% of the time. After adjustment for clinical scenario and chosen level of care, intensivists were more confident than nurses, who were more confident than housestaff (40% of intensivists, 29% of nurses, and 23% of housestaff were very confident). In general, healthcare workers tended to be more confident when they chose extreme levels of care than when they chose intermediate levels of care. Considerable variability in responses to scenarios remained even when we considered only those responses made with the highest level of confidence.

Conclusions While confidence in decisions about withdrawal of life support increases with seniority and authority, consistency of decisions may not. When given standard information, healthcare workers can make contradictory decisions yet still be very confident about the level of care they would administer. (Crit Care Med 1998; 26:44-49)

For the Canadian Critical Care Trials Group.

From the Departments of Clinical Epidemiology & Biostatistics (Drs. Walter, Cook, Guyatt, and Streiner); Medicine (Drs. Cook, Guyatt, and Jaeschke); and Psychiatry (Dr. Streiner), McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada; the Department of Surgery (Dr. Spainer), McGill University, Montreal, Quebec, Canada; and the Department of Surgery (Dr. Todd), University of Toronto, Toronto, Ontario, Canada.

Supported, in part, by the Ontario Ministry of Health. Dr. Walter is a National Health Scientist, National Health Research and Development Program, Health Canada, and Dr. Cook is a Career Scientist of the Ontario Ministry of Health.

© Williams & Wilkins 1998. All Rights Reserved.