Exploring the Impact of a Context-Adapted Decision Aid and Online Training About Shared Decision Making About Goals of Care with Elderly Patients in the Intensive Care Unit: A Mixed-Methods Study.

Purpose: The aim of this study was to evaluate the impact of an intervention-comprising a context-adapted decision aid (DA) and online shared decision-making (SDM) training for intensivists-on the quality of goals-of-care discussions (GCDs) and the level of involvement of elderly patients in those discussions within an intensive care unit (ICU).

Methods: This was a three-phase before-after mixed-methods implementation study conducted in an ICU in Lévis, Québec, Canada. We followed the StaRI and COREQ reporting guidelines. We recruited patients aged ≥ 65 years and their attending intensivists. We video-recorded GCDs in three phases: Phase I: GCDs without a DA; Phase II: GCDs with a DA about goals of care but no online training; and Phase III: GCDs with both a DA about goals of care and online training about SDM. All GCDs recordings were transcribed verbatim. We measured the level of patient engagement by intensivists in SDM about goals of care through the OPTION scale and evaluated GCDs quality using the Audit of Communication, Care Planning, and Documentation (ACCEPT) indicators. A qualitative thematic analysis of transcriptions of the encounters was also performed.

Results: Out of 359 eligible patients, the study included 21 patients (71% men; median age, 77 years; 57% without high school diploma) and five intensivists (80% men; median age, 35 years). Despite completing online training, the DA was never used in recorded encounters. We did not perform any tests of statistical significance to compare results in each study phase because of small sample sizes over each phase. OPTION and ACCEPT scores were low in each phase, but physicians did engage in GCDs. We found that 76% of documented goals of care for life-sustaining therapy were consistent with patient preferences expressed during recorded GCD, a determination made by two independent observers. Several patients expressed confusion about GCDs. Regarding the use of a DA to support SDM in GCDs, intensivists identified several barriers and facilitators. Barriers included physician attitudes, lack of training, and systemic pressures, while a patient-centered approach and positive patient attitudes were seen as key facilitators.

Conclusion: Despite implementing a context-adapted DA and online SDM training, this study found no significant improvement in the quality of GCDs or patient engagement, notably as the DA was not utilized. Communication barriers and patient confusion about goals of care highlight the persistent challenges in achieving true SDM in the ICU. Future strategies should focus on overcoming identified barriers for successful integration of such interventions.

Trial registration number: NCT04034979.