Audiovisual modules may improve knowledge and comprehension of ICU procedures, according to the results of a study of critically ill surgical patients and their legally authorized representatives.1

“This study was motivated by our observation that there are substantial barriers to obtaining informed consent for commonly performed ICU procedures,” says Tyler J. Loftus, MD, the study’s lead author and an assistant professor of acute care surgery at the University of Florida.

Time constraints limit clinicians’ ability to provide a full, detailed description of each procedure. “Verbal descriptions of complex medical and procedural concepts can be difficult for patients to understand without the use of audiovisual aids,” Loftus laments.

The audiovisual module described eight commonly performed ICU procedures. Most (75%) indicated the video was easy to understand, and 70% believed it improved their understanding of ICU procedures. “Bundled audiovisual ICU consent should not replace human interaction, which remains necessary to build trust and rapport with the patient and their caregiver,” Loftus cautions.

Decision-making capacity often is in question in the ICU. “Sometimes, it can be difficult to gauge whether someone has decision-making capacity, especially when someone might be experiencing hypoactive delirium,” says Kathleen Akgün, MD, MS, BS, director of the MICU at VA Connecticut Healthcare System.

If patients are on mechanical ventilators, or experiencing medication-induced sedation, clinicians need to obtain consent from surrogates instead. There also is the inherent difficulty of putting complex ICU procedures in simple terms anyone can understand. “We are also susceptible to cognitive biases, such as anchoring bias, where we focus on our first impressions of a patient’s diagnosis and best next steps for treatment,” Akgün says.

Akgün suggests ethicists offer round-the-clock coverage to support clinicians in obtaining consent for time-sensitive decisions.

Ethicists also could evaluate competence of informed consent practices on an ongoing basis. Providers might tend to overemphasize ongoing disease-targeted treatment, and not give as much emphasis to high-quality end-of-life care. For example, for the third time in five weeks, a patient presents with septic shock from advanced gastrointestinal cancer that is eroding into their intestines.

In that case, ICU providers may talk about decisions regarding central venous catheter placement for blood pressure support using vasopressors and antibiotic administration, without mentioning the alternative: focusing on comfort and allowing a natural death. “These concerns are potentially heightened with less bedside presence of surrogate decision-makers, as we have seen in the setting of the COVID-19 pandemic,” Akgün observes.

REFERENCE

  1. Loftus TJ, Alfaro ME, Anderson TN, et al. Audiovisual modules to enhance informed consent in the ICU: A pilot study. Crit Care Explor 2020;2:e0278.