Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment

Margot Smirdec, Mercé Jourdain, Virginie Guastella, Céline Lambert, Jean-Christophe Richard, Laurent Argaud, Samir Jaber, Kada Klouche, Anne Medard, Jean Reignier, Jean-Philippe Rigaud, Jean-Marc Doise, Russell Chabanne, Bertrand Souweine, Jeremy Bourenne, Julie Delmas, Pierre-Marie Bertrand, Philippe Verdier, Jean-Pierre Quenot, Cecile Aubron, Nathanael Eisenmann, Pierre Asfar, Alexandre Fratani, Jean Dellamonica, Nicolas Terzi, Jean-Michel Constantin, Axelle Van Lander, Renaud Guerin, Bruno Pereira, Alexandre Lautrette, Margot Smirdec, Mercé Jourdain, Virginie Guastella, Céline Lambert, Jean-Christophe Richard, Laurent Argaud, Samir Jaber, Kada Klouche, Anne Medard, Jean Reignier, Jean-Philippe Rigaud, Jean-Marc Doise, Russell Chabanne, Bertrand Souweine, Jeremy Bourenne, Julie Delmas, Pierre-Marie Bertrand, Philippe Verdier, Jean-Pierre Quenot, Cecile Aubron, Nathanael Eisenmann, Pierre Asfar, Alexandre Fratani, Jean Dellamonica, Nicolas Terzi, Jean-Michel Constantin, Axelle Van Lander, Renaud Guerin, Bruno Pereira, Alexandre Lautrette

Abstract

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://ichgcp.net/clinical-trials-registry/NCT03013530 .

Keywords: Advance directives; Decisions to forgo life-sustaining treatment; ICU.

Conflict of interest statement

The others authors have no financial conflict of interest related to this study.

Figures

Fig. 1
Fig. 1
Proportions of DFLSTs in round 1 (a) and round 2 (b). Legend: Black bars correspond to DFLSTs; Gray bars correspond to partial DFLSTs; White bars correspond to no-DFLSTs. S1: Scenario 1; S2: scenario 2; Q: Question
Fig. 2
Fig. 2
Main themes emerging from the advance directives

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