Physicians Rarely Elicit Critically Ill Patients' Previously Expressed Treatment Preferences in Intensive Care Units

• Published in: American journal of respiratory and critical care medicine 2017-07, Vol.196 (2), p.242-245
• Main Authors: Chiarchiaro, Jared, Ernecoff, Natalie C, Scheunemann, Leslie P, Hough, Catherine L, Carson, Shannon S, Peterson, Michael W, Anderson, Wendy G, Steingrub, Jay S, Arnold, Robert M, White, Douglas B
• Format: Article
• Language: English
• Subjects: Adult; Advance Care Planning; Advance Directives; Aged; Clinical decision making; Cohort Studies; Colleges & universities; Communication; Correspondence; Critical Illness; Decision making; Female; Humans; Intensive care; Intensive Care Units; Male; Mental competency; Middle Aged; Patient Preference; Physician-Patient Relations; Practice Patterns, Physicians; Professional-Family Relations; Prospective Studies; Qualitative Research; Respiratory Distress Syndrome - therapy; Right to die; Surveys and Questionnaires; United States
• ISSN: 1073-449X; 1535-4970
• DOI: 10.1164/rccm.201611-2242LE

The Centers for Medicare and Medicaid Services has announced reimbursement for discussing advance care planning. Conversations about previously expressed treatment preferences are important both because they may provide dispositive guidance for clinicians about what treatments the patient prefers and also because they may help surrogates make better in-the-moment judgments when the prior conversations did not address the specific clinical situation at hand. Eligible patients were aged 18 years or older, lacked decision-making capacity, required mechanical ventilation due to ARDS (3), and had a greater than or equal to 50% risk of in-hospital mortality or severe long-term functional impairment. In only 1 out of 245 conferences (0.4%) did surrogates provide information about the patient's previously expressed preferences that was dispositive for the clinical decisions at hand. The policy implication of these findings is that advance care planning should be directed at preparing surrogates for in-the-moment decision-making rather than trying to articulate an exhaustive list of treatment preferences (10). [...]it may be valuable for clinicians to reframe their expectations about how patients' previously expressed preferences will contribute to goals-of-care conversations in ICUs by moving away from expecting the information to be dispositive and toward using the information as a starting point for conversations about the patients' values. [...]we found that surrogates often had prior conversations about patients' treatment preferences; however, these preferences were rarely Washington Seattle, Washington Shannon S. Carson, M.D. University of North Carolina School of Medicine Chapel Hill, North Carolina Michael W. Peterson, M.D. University of California San Francisco Fresno...