Goals of Care Decision Making

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Design and Participants: This study investigated how intensivists facilitate decision making about goals of care for patients with CCI. The secondary aim identified physician-perceived barriers and facilitators to goals-of-care decision making. Semi-structured interviews were conducted with a purposeful sample of US and Canadian intensivists using a mental models approach adapted from decision science. Transcripts were analyzed inductively using qualitative description.

Results: In total, 29 intensivists (15 US, 14 Canada) from six institutions across three states and two provinces were interviewed (48% female); 62% worked in medical-surgical ICUs (mean=13 yrs experience [SD=8.2]), 69% worked in another setting in addition to ICU, and 28% had worked/trained in more than one country. Participants across all sites described decision making as a complex, longitudinal, and iterative process that involved substantial preparatory work, numerous stakeholders, and multiple family meetings. Intensivists required considerable time to collect information on prior events and conversations, and to arrive at a prognostic consensus with other involved physicians prior to meeting with families. Many intensivists stressed the importance of scheduling multiple family meetings to build trust and relationships prior to explicitly discussing goals of care. Physician-identified barriers to decision making included 1-week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members or families. Potential facilitators included scheduled family meetings at regular intervals, greater interprofessional involvement in decisions, and consistent messaging from care team members.

Commentary: Palliative care teams sometimes are consulted to help elicit goals of care in rapidly unfolding, complex, and charged situations—ideally a multistep process.3 More attention is going into requisite components to arrive at goal-concordant care, with new frameworks emerging to help guide professionals.4 The authors of this qualitative research study aim to understand how intensivists can improve goals-of-care conversations, only to recognize that facilitating factors may be at odds with the workflow and staffing models of the critical care setting. A next step to this research would be identifying and studying deliberate initiatives or system modifications, as the authors’ qualitative work points to valid shortcomings without identifying practical solutions.

Bottom Line: More research is needed to determine how to improve goals-of-care discussions for patients with chronic critical illness, particularly as the intensive care environment is a barrier to potentially facilitating factors such as interdisciplinary conversations with continuity professionals.

Reviewer: Sara Taub, MD MBE, Oregon Health & Science University, Portland, OR

References:

1. Dale CM, Carbone S, Istanboulian L, et al. Support needs and health-related quality of life of family caregivers of patients requiring prolonged mechanical ventilation and admission to a specialised weaning centre: a qualitative longitudinal interview study. Intensive Crit Care Nurs. 2020;58:102808.

2. Nelson JE, Kinjo K, Meier DE, Ahmad K, Morrison RS. When critical illness becomes chronic: informational needs of patients and families. J Crit Care. 2005;20(1):79-89.

3. Comer A, Fettig L, Torke AM. Identifying goals of care. Med Clin North Am. 2020;104(5):767-775.

4. Lanocha N, Taub S, Webb JA, Wood M, Tate T. It starts with a story: a four-step narrative-based framework for serious illness conversations. J Palliat Med. 2024;27(9):1177-1183.

Source: Andersen SK, Yang Y, Kross EK, et al. Achieving goals of care decisions in chronic critical illness: a multi-institutional qualitative study. Chest. 2024;166(1):107-117. doi:10.1016/j.chest.2024.02.015.

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