Dr Alicia Perez Blanco, Hospital Universitario de La Princesa, Madrid
Can advance care planning enhance decision-making at end-of-life in the Intensive Care Unit?
Although people from different western countries express their desire to discuss their end-of-life, the majority do not agree with their physician a plan that matches their values with their options for treatment. The Intensive Care Unit (ICU) is crucial in end-of-life decision making. The percentage of patients dying following withdrawal of life sustaining treatment (LST) in Europe, varies from 48% in northern countries to 18% in the south1. Any effort to discuss end-of-life care with patients, while they are competent, before or just after admission to ICU is of utmost importance. The majority of patients admitted to ICU would not have the opportunity to express how they want to be treated because they do not tend to be competent to decide about withdrawal of LST, have not completed Advanced Directives (AD) nor discussed preferences with next-on-kin. In the rare case that the patient has completed AD, clinicians rarely follow them for several reasons; patients may have changed their preferences without updating AD, in case of family conflict, clinicians could not override AD.
This paper presents the design and preliminary findings (Phase 1) of a study at the ICU of Hospital Universitario de La Princesa (Madrid, Spain) to measure the impact of introducing advance care planning (ACP) in critically ill patients early in the course of their illness as it may facilitate share decision-making among health care staff, patients, and proxies, and reduce over or under treatment by promoting debate about end- of-life issues2. The study has three phases. Phase 1) Two-year prospective observational study documenting present practice by reviewing current communication tools used by staff with patients/families to exchange information on prognosis and preference for end-of-life treatment. Phase 2) Implementation of an intervention consisting of a facilitator (nurse/physician specially trained in communication and emotional support) acting as a mediator to achieve share decision-making during meetings with treating physicians. Phase 3) Evaluation of Phase 2 intervention with a validated scale for anxiety (Generalized Anxiety Disorder -7) and a satisfaction exit questionnaire to families 3 months after discharge focused on communication and impact of the facilitator in end-of-life decisions. Length of stay from the physician’s proposal of LST withdrawal to death and monthly mortality rate in the ICU will also be compared. Analytical strategy: Quantitative descriptive analysis to describe the main features of numerical data and content analysis for free text data. Logistic regression for hospital mortality and Cox regression for length of stay will be used.
Findings of Phase 1 identified two main barriers to the implementation of a facilitator within the context of ICU:
a) Healthcare staff do not take into account patient’s values while they consider appropriate treatment options. First they follow evidenced based medical guidelines and then they consult the patient. Advance planning requires an inverse sequence: first consult the patient and then decide on best treatment.
b) Healthcare staff feel that they are doing their best at communicating with families/patients and may struggle to accept a facilitator except when conflict with patient/family has already occurred.
1 Carlet J, Thijs Lambertus G. Antonelli M, et al. Challenges in end of life care in the ICU. Intensive Care Med 2004; 30:770-84.
2 Joan M Teno, Hilde Lindemann Nelson Joane Lynn. Advance Care Planning Priorities for Ethical and Empirical Research. Hastings Center Report, November-December; 1994: S32-36.