Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study

Monika C Kerckhoffs, Jannien Senekal, Diederik van Dijk, Antonio Artigas, Jenie Butler, Andrej Michalsen, Margo M C van Mol, Rui Moreno, Filipa Pais da Silva, Edoardo Picetti, Pedro Póvoa, Annette Robertsen, Johannes J M van Delden, Monika C Kerckhoffs, Jannien Senekal, Diederik van Dijk, Antonio Artigas, Jenie Butler, Andrej Michalsen, Margo M C van Mol, Rui Moreno, Filipa Pais da Silva, Edoardo Picetti, Pedro Póvoa, Annette Robertsen, Johannes J M van Delden

Abstract

Objectives: To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries.

Design: A three-round web-based international Delphi consensus study with a priori consensus definition was conducted with experts from 13 countries. Participants reviewed items of the decision-making process on a seven-point Likert scale or with open-ended questions. Questions concerned terminology, content, and timing of decision-making steps. The summarized results (including mean scores) and expert suggestions were presented in the subsequent round for review.

Setting: Web-based surveys of international participants representing ICU physicians, nurses, former ICU patients, and surrogate decision makers.

Patients: Not applicable.

Interventions: Not applicable.

Measurements and main results: In three rounds, respectively, 28, 28, and 27 (of 33 invited) physicians together with 12, 10, and seven (of 19 invited) nurses participated. Patients and surrogates were involved in round one and 12 of 27 responded. Caregivers were mostly working in university affiliated hospitals in Northern Europe. During the Delphi process, most items were modified in order to reach consensus. Seven items lacked consensus after three rounds. The final consensus framework comprises the content and timing of four elements; three elements focused on caregiver-surrogate communication (admission meeting, follow-up meeting, goals-of-care meeting); and one element (weekly time-out meeting) focused on assessing preferences, prognosis, and proportionality of ICU treatment among professionals.

Conclusions: Physicians, nurses, patients, and surrogates generated a consensus-based framework to guide the process of decision-making on continuing or limiting life-sustaining treatments in the ICU. Early, frequent, and scheduled family meetings combined with a repeated multidisciplinary time-out meeting may support decisions in relation to patient preferences, prognosis, and proportionality.

Conflict of interest statement

Drs. Kerckhoffs and van Dijk’s institutions received funding from the LIFEPRIORITY foundation of the European Society of Intensive Care Medicine (ESICM) (King Baudouin Foundation 2017-j5920780-208088). Dr. Michalsen received funding from ESICM. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Flowchart Delphi process. Graphical representation of the methods of the Delphi consensus process.
Figure 2.
Figure 2.
Suggested format of the decision-making framework to use in practice. A, The three family meetings (admission, ICU follow-up and goals-of-care). B, The TIME-OUT meeting and additional resources.

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Source: PubMed

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