Effect of communication skills training on documentation of shared decision-making for patients with life-limiting illness: An observational study in an intensive care unit.

Objectives: This article aims to examine the association between a shared decision-making (SDM) clinical communication training program and documentation of SDM for patients with life-limiting illness (LLI) admitted to intensive care. Methods: This article used a prospective, longitudinal observational study in a tertiary intensive care unit (ICU). Outcomes included the proportion of patients with SDM documented on an institutional Goals of Care Form during hospital admission, as well as characteristics, outcomes, and factors associated with an SDM admission. Intervention: Clinical communication skills training (iValidate) and clinical support program are the intervention for this study. Results: A total of 325 patients with LLI were admitted to the ICU and included in the study. Overall, 184 (57%) had an SDM admission, with 79% of Goals of Care Form completed by an iValidate-trained doctor. Exposure to an iValidate-trained doctor was the strongest predictor of an ICU patient with LLI having an SDM admission (odds ratio: 22.72, 95% confidence interval: 11.91-43.54, p < 0.0001). A higher proportion of patients with an SDM admission selected high-dependency unit-level care (29% vs. 12%, p < 0.001) and ward-based care (36% vs. 5%, p < 0.0001), with no difference in the proportion of patients choosing intensive care or palliative care. The proportion of patients with no deterioration plan was higher in the non-SDM admission cohort (59% vs. 0%, p < 0.0001). Conclusions: Clinical communication training that explicitly teaches identification of patient values is associated with improved documentation of SDM for critically ill patients with LLI. Understanding the relationship between improved SDM and patient, family, and clinical outcomes requires appropriately designed high-quality trials randomised at the patient or cluster level.

Values, preferences and goals identified during shared decision making between critically ill patients and their doctors.

Objective: Examine values, preferences and goals elicited by doctors following goals-of-care (GOC) discussions with critically ill patients who had life-limiting illnesses. Design: Descriptive qualitative study using four-stage latent content analysis. Setting: Tertiary intensive care unit (ICU) in South Western Victoria. Participants: Adults who had life-limiting illnesses and were admitted to the ICU with documented GOC, between October 2016 and July 2018. Intervention: The iValidate program, a shared decision-making clinical communication education and clinical support program, for all ICU registrars in August 2015. Main outcome measures: Matrix of themes and subthemes categorised into values, preferences and goals. Results: A total of 354 GOC forms were analysed from 218 patients who had life-limiting illnesses and were admitted to the ICU. In the categories of values, preferences and goals, four themes were identified: connectedness and relational autonomy, autonomy of decision maker, balancing quality and quantity of life, and physical comfort. The subthemes - relationships, sense of place, enjoyment of activities, independence, dignity, cognitive function, quality of life, longevity and physical comfort - provided a matrix of issues identified as important to patients. Relationship, place, independence and physical comfort statements were most frequently identified; longevity was least frequently identified. Conclusion: Our analysis of GOC discussions between medical staff and patients who had life-limiting illnesses and were admitted to the ICU, using a shared decision-making training and support program, revealed a framework of values, preferences and goals that could provide a structure to assist clinicians to engage in shared decision making.

Defining patient-centered recovery after critical illness - A qualitative study.

PURPOSE: To explore perspectives of adult critical illness survivors and identify important aspects to care and recovery. MATERIALS AND METHODS: A descriptive, qualitative study of adult survivors of prolonged critical illness, six-months after Intensive Care Unit (ICU) discharge, using semi-structured interviews and thematic analysis. The study was undertaken in an academic, tertiary, regional hospital in Victoria, Australia. RESULTS: Thirty-five patients participated in the study. Most were male (69%) with median age 64 years. Admissions were predominantly medical (51%), followed by cardiothoracic (26%) and general surgical (23%). Median ICU and hospital length of stay were 5 and 17 days respectively. Qualitative analysis revealed two key theme categories, recovery status and care experience. Three recovery states were identified based on physical and neuropsychological recovery. Care experiences varied across recovery states, including care encounters, communication, support and impact on family and friends, and use of community health services. CONCLUSION: Critical illness survivors frame their recovery in terms of recovery status and care experience, reflecting existing qualitative domains of physical health, psychological health, cognitive function, social health and life satisfaction. Theme content varied with recovery status, raising the possibility that modifying care experiences or patient perceptions could change recovery outcomes.

Prevalence, goals of care and long-term outcomes of patients with life-limiting illness referred to a tertiary ICU.

OBJECTIVE: To describe the prevalence, characteristics, long-term outcomes and goals-of-care discussions of patients with objective indicators of life-limiting illnesses (LLIs) referred to the intensive care unit. DESIGN, SETTING AND PATIENTS: A prospective, observational, cohort study of all adult inpatients referred to the ICU by the medical emergency team or by direct referral, during the period 30 August 2012 to 1 February 2013, at a tertiary teaching hospital in Australia. MAIN OUTCOME MEASURES: Mortality, LLIs, discharge destination and documentation on goals of care in medical record. RESULTS: A total of 649 of 1024 patients referred to the ICU had an LLI, and only 34.4% of these patients had goals of care documented. Overall, 49.2% were admitted to the ICU, 48.4% were discharged home, and the 1-year mortality was 35.1%. The most common LLI criteria were heart disease (52.2%), chronic obstructive pulmonary disease (24.8%) and frailty (23.7%). The highest 1-year mortality was associated with pre-hospital residence in a nursing home (64.9%), dementia (63.3%), cancer (60.8%) and frailty (50.6%). Analysis of patients by clinical trajectory showed that 1-year mortality was significantly higher for patients with cancer (59.6%), combined organ failure and frailty (47.3%), frailty (43.8%) and organ failure (23.6%), compared with patients with no LLI (P < 0.0001). CONCLUSIONS: A high proportion of patients referred to the ICU have an LLI, and this is associated with prolonged hospital length of stay and a high 1-year mortality, and only one-quarter have documented discussions on goals of care. Patients with cancer-related and frailty-related LLIs have the worst survival trajectories.