A decision aid for prolonged mechanical ventilation did not improve prognostic concordance between clinicians and surrogates, according to the authors of a recent study.1 The tool did not reduce psychological distress among surrogates or alter clinical outcomes.
“A decision aid had never been tested in an acute care setting before,” explains Christopher Cox, MD, the study’s lead author and director of the medical ICU at Duke University. Researchers sought to help family members with the difficult task of making life-and-death decisions. They studied 277 adult patients who had been on life support at least 10 days, 416 surrogates, and 427 clinicians (ICU nurses and ICU physicians) at 13 medical-surgical ICUs at five hospitals. Key findings:
- Surrogates’ post-intervention estimates of patients’ one-year prognoses did not differ between intervention and control groups;
- Many surrogates (43%) favored a treatment option that was more aggressive than their report of patient preferences.
The researchers were surprised that the decision aid did not really change the decisions made or the amount of time patients were hospitalized. “This is humbling because decisions aids have been promoted as a way to reduce costs of care,” Cox notes. Family caregivers answered questions about the patient’s values, then the computer-based guide made treatment recommendations. However, these were disregarded in more than half of cases. Families frequently chose a more aggressive goal of treatment than the patient’s values suggested.
“Our findings highlight the complexity of end-of-life decision-making,” Cox says.
- Cox CE, White DB, Hough CL, et al. Effects of a personalized web-based decision aid for surrogate decision makers of patients with prolonged mechanical ventilation: A randomized clinical trial. Ann Intern Med 2019; Jan 29. doi: 10.7326/M18-2335. [Epub ahead of print].