학술논문
Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment
Document Type
Report
Author
Smirdec, Margot; Jourdain, Mercé; Guastella, Virginie; Lambert, Céline; Richard, Jean-Christophe; Argaud, Laurent; Jaber, Samir; Klouche, Kada; Medard, Anne; Reignier, Jean; Rigaud, Jean-Philippe; Doise, Jean-Marc; Chabanne, Russell; Souweine, Bertrand; Bourenne, Jeremy; Delmas, Julie; Bertrand, Pierre-Marie; Verdier, Philippe; Quenot, Jean-Pierre; Aubron, Cecile; Eisenmann, Nathanael; Asfar, Pierre; Fratani, Alexandre; Dellamonica, Jean; Terzi, Nicolas; Constantin, Jean-Michel; Van Lander, Axelle; Guerin, Renaud; Pereira, Bruno; Lautrette, Alexandre
Source
Critical Care. December 2, 2020, Vol. 24 Issue 1
Subject
Language
English
ISSN
1364-8535
Abstract
Author(s): Margot Smirdec[sup.1] , Mercé Jourdain[sup.2] , Virginie Guastella[sup.3] , Céline Lambert[sup.4] , Jean-Christophe Richard[sup.5] , Laurent Argaud[sup.6] , Samir Jaber[sup.7] , Kada Klouche[sup.8] , Anne Medard[sup.9] , Jean Reignier[sup.10] [...]
Background There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. Methods We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients' characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). Results A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p < 0.001). High inter-intensivist variability did not change with ADs (RSD: 0.56 (round 1) vs 0.46 (round 2), p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain. Conclusions ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist's decision took priority. Further research is needed to improve the matching of the physicians' decision with the patient's wishes. Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://clinicaltrials.gov/ct2/show/NCT03013530. Keywords: Advance directives, Decisions to forgo life-sustaining treatment, ICU
Background There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. Methods We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients' characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). Results A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p < 0.001). High inter-intensivist variability did not change with ADs (RSD: 0.56 (round 1) vs 0.46 (round 2), p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain. Conclusions ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist's decision took priority. Further research is needed to improve the matching of the physicians' decision with the patient's wishes. Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://clinicaltrials.gov/ct2/show/NCT03013530. Keywords: Advance directives, Decisions to forgo life-sustaining treatment, ICU