Perspectives of continuous renal replacement therapy in the intensive care unit: a paired survey study of patient, physician, and nurse views

Our study describes the single-center experience of mismatch around patient/HCP and provider perceptions of CRRT using a non-validated survey tool and descriptive analysis techniques. Of note, most patients in this cohort were too ill to participate in a survey, and therefore 88 % of responders from the patient/HCP group were HCPs. While HCPs often must make decisions for patients in the ICU, it should be noted that HCPs represented the majority of the patient/HCP subgroup, and may not necessarily have the same views or understanding as the patients themselves.

One of the most prominent findings in this study was that all three subgroups – patients/HCPs, ICU physicians, and nurses – provided answers that were inconsistent with published literature around survival and likelihood of requiring long-term dialysis. Forty-four percent of ICU physicians and nurses identified in-hospital mortality rates consistently with the literature, as did just 6 % of patients/HCPs. All three subgroups were similarly discrepant in assessing the likelihood of requiring long-term dialysis compared to prior studies. While both nurses and physicians were significantly more consistent with published probabilities of survival than patients/HCPs, these responses highlight a need for further education for patients and providers alike. Our results are consistent with prior literature examining attending and resident physicians’ accuracy of prognosis. Survey studies around patients with acute congestive heart failure, late stage cancer, and critical illness requiring ICU admission described similarly low rates of prognostic accuracy. [13, 37‐39] At our study site, consulting nephrologists, rather than ICU physicians or nurses, obtain informed consent for CRRT. This study did not assess the degree of communication between consulting nephrologists and the ICU care team and patients/HCPs. The consent process is a natural time for patients/HCPs to ask questions about survival and potential long-term dialysis needs; this interaction may serve as another potential target for investigation of perceptions of CRRT.

This study included only patients who were initiated on CRRT, as opposed to intermittent hemodialysis. While studies comparing outcomes between these two populations have shown similar rates of survival and long-term dialysis dependence, [40] the results of this study are best generalized to the CRRT population. It should also be noted that the 97 % of patient/HCPs identified as having a high school education or greater. Those with lower education levels might have even worse prognostic estimates, though this conjecture requires further study to evaluate in the CRRT population.

Compared to their physicians, our results show that patients/HCPs overestimate the chance of survival, which is consistent with prior literature comparing patient and provider views in the non-ICU setting. [12‐17] Our study is novel in that it also examines ICU nurses’ perceptions of patient outcomes. Despite the fact that nurses have more direct contact with patients/HCPs than physicians, [41, 42] we found no differences in the responses of physicians and nurses. Nurses’ understanding of illness may have a strong impact on patient/HCP perceptions and expectations, and thus highlights an additional opportunity for interventions to improve understanding of prognosis and communication in the ICU. This concept requires further directed study to examine the impact of nursing beliefs of illness on care of patients with CRRT.

Perhaps the richest patient/HCP information came in open-ended responses to question 1. Overall, responses spanned several thematic areas important to the function of CRRT. With few exceptions, patients/HCPs were generally accurate in describing some of the reasons CRRT was employed. Answers were typically short, and very few patients talked about CRRT as a life-supporting measure. Answers typically focused on the mechanical function of the device – commonly described as a filter, a “slow” treatment, or as an extracorporeal device with blood being removed then returned to the body. It is not known if this pattern of responses was because the idea of CRRT as life support (analogous to a ventilator, for example) was not emphasized during the consent or patient education process, or because this was difficult of patient/HCPs to acknowledge.

There is an interesting paradox that exists in the literature surrounding communication of advanced illness. Even after candid conversations about advanced care planning, patient/HCP understanding of prognosis and surrogate decision-making preferences has been shown to be low. [43, 44] However, recent data suggests that many patients prefer to hear from their doctor if their overall prognosis is poor, suggesting that providers should feel both empowered and obligated to share as much prognostic information as appropriate with patients and HCPs. [45, 46] These discussions can be challenging in the ICU setting, however, due to lack of consistent prediction models, frequently evolving treatment courses, variations in patient/HCP belief systems, and the emotional stresses inherent to the ICU. [3, 18‐25] At this study site, there is no standardized patient education process around CRRT, which may be a barrier to improving discordance around CRRT. Augmenting direct clinician counseling with multimedia educational tools, such as decision support videos, has been shown to be successful in improving patient/HCP understanding of illness and assisting in making decisions consistent with patients’ value systems. [47] These tools have been used in other patient populations with poor overall prognosis, including counseling about cardiopulmonary resuscitation in the ICU. [48‐53] Our study highlights a significant knowledge gap and communication mismatch between patients/HCPs and ICU providers around CRRT, suggesting that there may be a role for such a tool around this intervention.

This study should be interpreted with the context of its limitations. It was performed at a single site using a small sample, thus potentially limiting generalizability. Since this study was not powered to pick up individual predictors of accuracy, no patient or HCP demographic factors correlated with answer choices. However, this study was designed in large part to be a descriptive and qualitative investigation of perceptions of illness across parallel patient and provider groups. We feel that our holistic message is more important than the power of the individual data points. ICU physicians and nurses were instructed to answer based on perceptions of overall survival and renal recovery rates (rather than for the index patient case) in order to maximize objectivity and comparability between groups. However, provider expectations for each index patient may have had an influence on answer choices due to temporal proximity to the survey, thus capturing some degree of bias. In line with this, the survival rate in this sample was 59 %, which is higher than the rates of less than 50 % that are routinely published in the literature. This is likely explained by a selection bias, as sicker patients who had a higher mortality were more likely to die (or transitioned to comfort care measures) prior to being interviewed, thus artificially improving survival in our sample. Still, this may have affected responses in all three subgroups. Because no validated survey tool previously existed that could assess the questions of this study, our research group had to create our own short survey. Prior studies assessing patient understanding of illness in hemodialysis and in the ICU have done so with similar, non-validated survey tools, [17, 50] so we feel that are results remain interpretable. Prior to the beginning of the study, the survey tool was reviewed by two members of each subgroup in order to ensure understandability. These subjects were not included in the final analysis.