Prior Advance Care Planning Is Associated with Less Decisional Conflict among Surrogates for Critically Ill Patients

Abstract

Rationale: Although numerous studies have documented that family members in intensive care units struggle with end-of-life decisions for incapacitated patients, there is little information about whether prior advance care planning lessens the burden of decision making.

Objectives: We sought to measure decisional conflict in surrogates of critically ill patients and to examine whether prior advance care planning is associated with less decisional conflict.

Methods: We performed a secondary data analysis of a multicenter, prospective cohort study done at five U.S. academic medical centers that included 471 surrogates of 257 patients with acute respiratory distress syndrome. The main outcome was surrogates' burden of decision making as measured using the Decisional Conflict Scale. Surrogates completed a questionnaire item addressing whether they had had any prior advance care planning conversations with their loved ones. We used multilevel linear regression modeling to measure the association between decisional conflict and advance care planning.

Measurements and main results: Moderate or high levels of decisional conflict (Decisional Conflict Scale score≥25) were present in 48% of surrogates. After adjusting for potential confounders, surrogates who had engaged in prior advance care planning conversations had significantly lower levels of decisional conflict than those who had not (mean score 3.3 points lower on the Decisional Conflict Scale; 95% confidence interval, -6.4 to -0.2; P=0.03).

Conclusions: Nearly half of surrogates for critically ill patients have moderate or high levels of decisional conflict. Prior advance care planning was associated with less decisional conflict. These results suggest that the scope of the benefit of advance care planning may extend beyond respecting patients' wishes to also ameliorating the burden on patients' loved ones who act as surrogates.

Keywords: cohort study; communication; critical illness; decision making; respiratory distress syndrome.

Figures

Figure 1.

Distribution of decisional conflict by completion of advance care planning (ACP).

Figure 2.

Distribution of surrogates’ self-rated understanding of which treatments their loved one would want by completion of advance care planning (ACP).