|
 These conversations are an essential component of so-called shared
decision making, which depends on clinicians taking the time to
explain the benefits and harms of treatment options and also
listening to patients and families explain what they hope to gain
from any interventions. When it's done right, shared decision making
improves patient satisfaction and helps ensure that care plans are
designed to achieve outcomes most important to patients and
families.
For the current study, researchers assessed what transpired in 244
conferences between clinicians and families of patients in acute
respiratory distress and at least a 50 percent chance of dying in
the hospital.
Patients were 58 years old on average and hospitalized in intensive
care units (ICUs). They were unable to advocate for themselves;
families had to decide what treatment to provide, and when to focus
on comfort care rather than aggressive interventions.
Only 68 percent of these conferences included discussions of
patients values and preferences for end of life care, researchers
report in JAMA Internal Medicine. And these conferences specifically
applied patients' values to treatment decisions just 44 percent of
the time.
Done right, good communication "can provide people time to say
good-bye, to participate in religious or spiritual rituals, to
complete items on a 'bucket list,' and sometimes even to die at
home," said lead study author Dr. Leslie Scheunemann of the
University of Pittsburgh Medical Center.
"It can improve symptom management, reduce suffering, and provide
emotional support to families," Scheunemann said by email.
"Conversely, worse communication can contribute to patients
receiving potentially burdensome treatments they would not have
wanted, distract people from saying good-bye, and increase how
stressful and burdensome decision-making is for families."
In only 36 percent of the conferences did clinicians and families
discuss important considerations for end-of-life care like how much
patients would want to retain cognitive, physical or social
functioning or the role of spirituality in their lives.
[to top of second column] |
Clinicians made treatment recommendations based on patients'
preferences in just eight percent of the conferences.
The study wasn't a controlled experiment designed to prove whether
or how these conferences might improve shared decision making or how
giving patients and families more say in their care might impact
quality or patient satisfaction.
"Physicians tend to focus on making a decision about the processes
of care (should we intubate? should we resuscitate?) whereas
patients and families think about the outcomes of that care," said
Dr. Terri Fried of the Yale School of Medicine in New Haven,
Connecticut, and the VA Connecticut Healthcare System, in an email.
"If this is not fully discussed at the time a treatment decision
needs to be made in the ICU, then patients won't receive the care
that is either most likely to achieve the outcomes they want or
avoid the outcomes they don't want," said Fried, who wrote an
editorial about the study.
Patients and families may need to speak up and ask very direct
questions to ensure they get the care that feels like the best
choice for their specific circumstances and values, Fried advised.
"Patients (if they are able) and families (if they are making
decisions on behalf of a patient) need to ask doctors to be clear on
what all the reasonable choices are in any situation, and what is
most likely to happen if they pursue one choice or another," Fried
said. "One strategy that is gaining in popularity is to ask
physicians about the best case and worst case that could result from
each choice."
SOURCE: http://bit.ly/2WFmzMg JAMA Internal Medicine, online April
1, 2019.
[© 2019 Thomson Reuters. All rights
reserved.] Copyright 2019 Reuters. All rights reserved. This material may not be published,
broadcast, rewritten or redistributed.
Thompson Reuters is solely responsible for this content.
 |
