Typologies of decision-makers in the ICU: A mixed methods study of ARDS and sepsis patients and their surrogates Öffentlichkeit

Abstract

Poor communication between physicians and patients/surrogates in the ICU leads to increased burnout in clinicians and increased anxiety and depression in surrogates. Further there is low concordance between patient and surrogate decision making. Unfortunately, little is known about patient and surrogate's rationale for end-of-life decision making while in the ICU, which may improve communication. To develop hypotheses of patient and surrogate's rationale for decision making as well as assess patient and surrogate concordance, we pursued a mixed methods study of patients with ARDS or sepsis and their surrogates. 14 patients and 28 surrogates were given semi structured interviews while in the ICU, and again 30 days later. The interviews focused on goal outcomes for the ICU stay, and why a patient or surrogate would want a specific intervention (e.g. intubation or CPR). These interviews were analyzed using grounded theory and the constant comparative method on NVivo 10.0, as well as SAS for quantitative comparisons. We found that only 3 out of 10 dyads agreed completely across all possible outcomes, and a non-significant trend with surrogates more likely to find an outcome 'good' compared to patients. We also noted a non-significant trend towards an improved view of outcomes at 30 days compared to being in the ICU. Qualitatively, we identified 4 typologies of decision making rationale: 1) "Timers"- determined decisions based on length of time on life support 2) "Natural Livers"- rejected interventions using a 'machine' 3) "Deferrers"- Relied on physician for decision making and prognosis and 4) "Believers"- relied on a higher power. Our hypothesized typologies need validation in a prospective observational trial. If validated, they may allow for better clinician communication and more focused interventions on surrogates at risk of long term psychological morbidity.

Table of Contents

Table of Contents:

Page 1- Introduction Page 3- Background Page 6- Methods Page 14- Results Page 31- Discussion Page 41- References Page 46- Table 1: Key Interview Questions Page 47- Figure 1: Study Flow Sheet Page 48- Figure 2: Patient Demographics Page 49- Figure 3: Sensitivity Analysis Page 50- Figure 4: Patient and surrogate concordance, paired Page 51- Figure 5: Patient vs. surrogate concordance, unpaired Page 52- Graph 1: Percent finding outcomes ‘good', patient vs. surrogates Page 53- Figure 6: Stability of views on what constitutes a ‘good' outcome Page 54- Graph 2: Percent finding outcome ‘good,' ICU vs. post discharge Page 55- Figure 7: Stability of views on what constitutes a ‘good' outcome, McNemar test Page 56- Table 2: Quotes by typology Page 60- Figure 8: Views on what constitutes a ‘good' outcome, by typology

About this Master's Thesis

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School	Laney Graduate School
Department	Clinical Research Curriculum Program
Degree	MS
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Medicine and Surgery
Stichwort	Surrogate decision making Patient decision making End-of-life decision making
Committee Chair / Thesis Advisor	Sevransky, Jonathan, Emory University
Committee Members	Escoffery, Ngoc Cam, Emory University Klein, Mitchel, Emory University

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