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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