15 Shared decision making in goals-of-care conversations with elderly patients: concerns and limitations

Abstract

Background In goals-of-care conversations, patients’ prognosis, level of functional autonomy, values and life goals are discussed in order to inform decisions regarding the use of life-sustaining interventions. Without such discussions, interventions that prolong life at the cost of decreasing its quality may be used without appropriate guidance from patients. Shared decision making (SDM) is recommended to support these goals-of-care conversations. Decision aids (DA), providing unbiased, evidence-based information to patients, can help clinicians engage in SDM. We developed a DA adapted to the context of an Intensive Care Unit (ICU) and a training program that could support these goals-of-care conversations. Objectives We aimed to: (i) determine to which extent DA use and training increase intensivists’ SDM related skills, (ii) identify elderly patients’ concerns regarding goals-of-care and whether and how they are addressed during the conversation, and (iii) identify opportunities for intensivists to improve their SDM skills. Methods We conducted a three-phase study using mixed-methods analysis, in a single ICU (Lévis, Canada), recruiting intensivists to participate in the training program and use the DA during real life goals-of-care conversations. We recruited elderly patients (>65 years) with whom intensivists intended to engage in a goals-of-care conversation. We videotaped goals-of-care conversations in three phases: (i) prior to the training session and DA availability, (ii) with the DA available for use, (iii) after the training session (and DA availability). We conducted a videographic analysis to assessed the degree of SDM related behaviour displayed (12-item OPTION scale, min-max scores: 0–48) and a retrospective qualitative content analysis to address goals-of-care elements addressed during conversations. Results We recruited 7 dyads per phase for a total of 21 patients (71% male; mean age 76 years) and 5 intensivists (80% male). None of the 21 conversations were supported by the DA. Median OPTION score were 12 (interquartile range [IQR]: 10–14), 10 (IQR: 7–12) and 9 (IQR: 8–14) for the three phases respectively. Content analysis showed that intensivists tended to focus on medical interventions rather than talking about death/dying and avoided addressing options of not attempting cardiopulmonary/mechanical ventilation. When intensivists talked about death and dying, they used euphemisms and metaphors referring to the human body as a machine. Conclusion Our results show that the intensivists never used the DA and avoided discussing death and dying and the option of not attempting cardiopulmonary/mechanical ventilation in the case of a cardiac arrest/respiratory failure during the three study phases.