Introduction
Quality indicators for communication
Quality indicators for patient- and family-centred decision-making
Objectives and research questions
Material and methods
Ethics
Search strategy
Criteria for eligibility of studies
Inclusion criteria
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The following were the study inclusion criteria:
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The study addressed a clear research question or objective, and primary collected qualitative or quantitative data were used.
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ICU physicians treating adult patients were reported. Intensive care physicians were defined as attending physicians, critical care fellows, resident physicians or consultants. In studies that included various types of intensive care clinicians, separate results for physicians had to have been reported.
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The report was on physician communication within the team and with patients and families or on patient and family-centred decision-making towards the end of life of patients in an ICU.
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The report was on physician-related barriers to communication and patient and family-centred decision-making as described by the physicians themselves (physician-reported) and not by other caregivers of the ICU-team (for example, nurses), by patients or by proxies or relatives. The focus was on barriers that can be changed; therefore age, sex and background of the physicians were not included as barriers.
Exclusion criteria
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The report was on medical students, nurses or patients and their families.
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The report was on physicians in nonadult ICUs (for example, neonatal ICU).
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The study had a quality assessment score of 5 or lower assigned independently by MV and DH.
Study selection
Data collection
Quality assessment and grading evidence
Results
Study selection
Characteristics and quality assessment of included studies
Study (yr) [ref] | Country | Study objective | Study design | Participants | Quality assessment |
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Qualitative studies
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Pattison et al. (2013) [15] | UK | To explore the meaning of end-of-life care for critically ill cancer patients, their families, oncologists, palliative care specialists, critical care consultants and nurses | Qualitative, phenomenological, in-depth interviews | 13 physicians | 9 |
Gutierrez (2012) [16] | USA | To explore the experiences of critical care nurses and physicians with advance directives in an intensive care unit (ICU) to identify the benefits and limitations of advance directives and recommendations for improvement | Descriptive ethnographic study with interviews in a 22-bed medical/surgical ICU in a large community hospital | 7 attending physicians, 3 fellow physicians | 6.5 |
Barnato et al. (2012) [17] | USA | To explore norms of decision-making regarding life-sustaining treatments at 2 academic medical centres that contribute to opposite extremes of end-of-life ICU use | Mixed-methods study: family meetings, informal and formal interviews, and artefacts | Attending physicians at 2 academic medical centres, patients and family | 8 |
Schenker et al. (2012) [18] | USA | To describe whether and how comfort care was presented as an option in family conferences about treatment options, and to assess whether the strength of the physicians’ belief that life support should be withdrawn was associated with the presentation of comfort care | Mixed-methods study of 72 audio-recorded family conferences about end-of-life treatment decisions | Physicians and family | 8 |
Jox et al. (2012) [19] | Germany | To explore how clinicians themselves define medical futility, whom they think should assess this, how they justify performing futile treatment and how they communicate futility situations to patients and caregivers | Qualitative mixed-methods approach at a large tertiary referral centre used to analyse protocols of ethics consultations and semistructured interviews | 7 physicians | 8.5 |
Baggs et al. (2012) [20] | USA | To examine the role of the `attending physician’ in four adult ICUs and the consequences of role complexities for clinicians, as well as for patients and their families, particularly in the context of end-of-life decision-making | Ethnographic study in a large academic hospital with surgical, medical, cardiovascular and burn/trauma ICU, including observations of end-of-life discussions and interviews | 30 physicians | 8.5 |
Coombs et al. (2012) [21] | UK | To identify the challenges for health care professionals when moving from a recovery trajectory to an end-of-life trajectory in intensive care | Semistructured interviews in 2 ICUs in a large university-affiliated hospital in England | 13 doctors | 9 |
Ahern et al. (2012) [22] | Canada | Interview-based qualitative study conducted to identify what is important to physician trainees in the ICU and infer from this positive educational experiences for physician trainees | Qualitative approach of hermeneutic phenomenology, semistructured interviews | 19 critical care physician trainees in their postgraduate years (R4 to R6) | 8.5 |
Gehlbach et al. (2011) [23] | USA | Assess the concordance between patients’ code status preferences and their actual code status orders; compare patients/surrogates and their physicians regarding their respective assessments of most important goals of care | Survey, interviews with closed-ended and open-ended questions in a medical ICU of a large academic medical centre | 15 physician participants | 7.5 |
Schwarze et al. (2010) [24] | USA | To examine the culture and practice of surgeons to assess attitudes and concerns regarding advance directives for their patients who undergo high-risk surgical procedures | Qualitative study in trauma and surgical critical care | 10 physicians | 7.5 |
Corke et al. (2009) [25] | Australia | To examine attitudes of intensive care doctors to advanced care planning and medical enduring power of attorney | Survey followed by open-ended questions | 275 trainees and fellows | 7 |
Sibbald et al. (2007) [26] | Canada | To explore how frontline ICU staff defines medically futile care, to discover why they provide it and to identify strategies that might promote a more effective use of ICU resources | Qualitative interviews in 16 ICUs of academic and community hospitals | 16 medical directors | 8 |
Beck et al. (2008) [27] | Germany | To identify difficulties and uncertainties in making decisions about withholding and withdrawing mechanical ventilation among intensive care physicians | Problem-centred interviews | 28 interviewees, 4 consultants, 11 senior registrars, 13 senior house officers (20 of 28 were specialists) | 9 |
Baggs et al. (2007) [28] | USA | To clarify unit cultures surrounding end-of-life decision-making in 4 US adult medical and surgical ICUs | Prospective ethnographic study of 4 adult ICUs in which a 6-member research team used participant observations, field notes, and semistructured interviews of health care providers as well as patients and their families | 13 physicians | 8 |
White et al. (2007) [29] | USA | To determine the nature and extent of shared decision-making about end-of-life treatment in ICUs, which factors are predictive of higher levels of shared decision-making | Mixed-methods study: ICU family conferences in 1 county hospital, 1 university hospital and 2 community hospitals, as well as questionnaires to physicians | 35 physicians leading conferences | 8.5 |
Hsieh et al. (2006) [30] | USA | To identify inherent tensions that arose during family conferences in the ICU and the communication strategies clinicians used in response | Qualitative content analysis; communication between family members and physicians was analysed using a dialectic perspective in 51 family–clinician conferences in 4 hospitals | 36 physicians who led the conferences | 8.5 |
Palda et al. (2005) [31] | Canada | To explore the process of the provision of futile care in Canadian ICUs | Survey with closed- and open-ended questions | 114 physicians | 6.5 |
West et al. (2005) [32] | USA | To identify categories of expressions of nonabandonment in the setting of ICU family conferences concerning withdrawing life-sustaining therapy or the delivery of bad news, and to develop a conceptual model in which nonabandonment is expressed | Qualitative analysis of statements of abandonment during family conferences discussing withholding/withdrawing of treatment | 35 physicians leading the conferences | 7.5 |
Quantitative studies
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Bülow et al. (2012) [33] | European countries (6 countries) | To examine whether religion and religiosity are important to end-of-life decisions and patient autonomy in the ICU | Structured questionnaires in 6 European countries, 143 ICUs | 304 physicians | 6 |
Schimmer et al. (2012) [34] | Germany | To determine the decision-making process of withholding and/or withdrawing of life-sustaining treatment in cardiac ICUs in Germany | Questionnaire distributed to all heart surgery ICUs (N = 79) in Germany | 35 clinical directors, 25 senior ICU physicians | 6 |
Kübler et al. (2011) [35] | Poland | To analyse the attitudes of ICU physicians regarding decisions to forgo life-sustaining treatment for adult ICU patients | Survey | 217 intensive care physicians working in ICUs in Poland | 6 |
Weng et al. (2011) [36] | China | To document current attitudes and practices of ICU doctors in China dealing with issues that have strong ethical and moral dimensions; to make comparisons with these attitudes and practices reported by ICU doctors in Hong Kong and Europe | Anonymous, written, structured questionnaire survey | 315 participants, representing 54 ICUs in 30 cities in 21 of the 31 regions of China | 7 |
Kranidiotis et al. (2010) [37] | Greece | To study the frequency, type and rationale for limiting life support in Greek multidisciplinary ICUs, the clinical and demographic parameters associated with limiting life support, and the participation of relatives in the decision-making process | Prospective observational study, with an anonymous questionnaire in 8 multidisciplinary, general hospital-affiliated ICUs | 304 patients and their physicians | 7 |
Schaden et al. (2010) [38] | Austria | To explore Austrian intensive care physicians’ experiences with, and their acceptance of, the new advance directives legislation 2 years after enactment | Survey of all ICUs in Austria | 139 participants | 6 |
Westphal and McKee (2009) [39] | USA | To examine differences between physicians and nurses regarding knowledge about advance directives and do-not-resuscitate orders, and the personal factors that underlie beliefs and practices related to the use of advance directives and do-not-resuscitate orders | Survey | 53 physicians | 6 |
Sprung et al. (2008) [40] | European countries (17 countries) | To evaluate physician documentation and the reasoning, considerations and difficulties in end-of-life decision-making in ICUs | Prospective study of end-of-life practices and decisions in consecutive patients who died or were subject to any limitation of life-saving interventions in 37 ICUs in 17 European countries | ICU physicians | 6 |
Collins et al. (2006) [41] | Ireland | To study the frequency, rationale and process for withholding and withdrawing life-sustaining treatment in intensive care patients in Ireland | Prospective observational study of all consecutive patients admitted to ICU who died or had life-sustaining treatment limited | Data of 122 patients, documented by physicians | 7 |
Nelson et al. (2006) [42] | USA | To improve the understanding of educational needs among residents caring for the critically ill | Survey | 184 physicians | 7 |
White et al. (2006) [43] | USA | To determine how decisions are made to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision makers | Prospective longitudinal cohort study | 47 physicians of patients without decision-making capacity and without a surrogate | 6 |
Moss et al. (2005) [44] | USA | To assess the knowledge, skills and attitudes that physicians and nurses who practice in West Virginia’s ICUs have concerning end-of-life care | Survey | 153 physicians | 6 |
Cohen et al. (2005) [45] | European Countries (17 countries) | To examine the communication of end-of-life decisions in Europe | Prospective observational study of 4,248 patients who had any limitation of life-sustaining treatment or died in 37 ICUs in 17 countries | Physicians collected data on 4248 patients | 7 |
Élő et al. (2005) [46] | Hungary | To study the factors associated with limiting resuscitation in Hungary | Survey | 72 doctors | 7 |
Sinuff et al. (2004) [47] | Canada, USA, Sweden, Australia | To study the rate of establishing do-not-resuscitate directives, determinants and outcomes of those directives for mechanically ventilated patients | Multicentre observational study | 3,099 critically ill patients admitted to 15 ICUs, documentation attending physicians' clinical judgements | 7 |
Yap et al. (2004) [48] | Hong Kong | To examine ethical attitudes of intensive care physicians in Hong Kong | Survey | 65 physicians | 7 |
Hariharan et al. (2003) [49] | West Indies | To analyse the characteristics of moribund patients in a surgical ICU and highlight the dilemmas inherent in treating such patients | Prospective collection of data from patient records | Data of patients recorded by physicians of surgical ICU | 6 |
Garland and Connors (2007) [50] | Canada | To quantify the influence that ICU staff physicians have on decisions to limit life support for critically ill patients | Data prospectively collected in the 13-bed medical ICU of a 520-bed urban university-affiliated teaching hospital | 9 staff physicians | 7 |
Barriers
Quality indicator no. a | Barriers with regard to physicians' knowledge |
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General | • Insufficient physician training in communication about end-of-life issuesb [42] |
• Clinician reluctance to use opioids or sedatives because of concern about side effectsb [42] | |
• Lack of education in palliative medicineb [44] | |
1 | • Involvement of surgeons slows down decision-making because they do not understand patient’s situationc [21] |
2 | • Lack of communication skills of senior medical residents when interacting with colleaguesc [22] |
5 | • No familiarity with skilled and timely communicationc [26] |
10 | • Not taught how to recognize that a person is about to die, no awareness of the process of dyingc [21] |
• Unrealistic expectations by clinicians about patient prognosis or effectiveness of ICU treatmentb [42] | |
16 | • Physician uncertainty about the legal details of advance directivesb [38] |
• Physician lack of physician experience with advance directivesb [38] | |
21 | • Lack of familiarity to make a prognosisc [15] |
• Not knowing how to deal with `feeling helpless• with families pressuring ICU teams to withhold treatment or when family members are upset about aggressiveness of care provided to their unwilling loved onec [22] | |
• Uncertainty concerning the services provided by local hospice programs and whom to refer to hospicesb [44] | |
• No awareness of professional or local guidelines that related to provision of futile careb [31] | |
• Insufficient training in communication with patients and their familiesb [31] | |
• Lack of discussion of ethical issues in medical programmes; lack of knowledge of ethical issues concerning end-of-life decisionsb [48] | |
22 | • No familiarity with defining futility and how to communicate futility to patients and their familiesc [19] |
• No knowledge of management of critical illness by referring specialists; confounding factors in decision-makingc [21] | |
23 | • Conditioned that doing nothing or withdrawing treatment is not helping patientc [19] |
• No awareness of end-of-life care guidelinesc [27] | |
• Not being at ease in talking to patients and their families about limitations of therapyb [36] | |
• No familiarity with end-of-life decision-making (`good prognosis' and `give it a go'often said because of no familiarity with end-of-life decision-making)b [25] | |
• Insufficient clinician training in techniques for forgoing life-sustaining treatment without causing patient sufferingb [42] |
Quality indicator no. a | Barriers with regard to physicians'attitudes |
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1 | • Lack of consensus among the treating team in making end-of-life decisions, surgeons in the ICU do not want to give responsibility to other members of the clinical team, looking only at the small percentage of patients who survive, and one physician could push for futile treatment looking only at a small aspect of the patient’s overall conditionb [20],[26] |
• Perception by the critical care attending physician that the consulting specialist controls life-sustaining treatment decision-makingc [17] | |
2 | |
Surgeon’s disagreement with other consultants to accept futility treatmentd [49] | |
5 | • Negative attitude towards relatives who want limitation of treatmentd [37] |
6 | • Family is thought not to understand end-of-life practice, family was considered not available, or physicians found discussion with relatives unnecessaryd [37] |
10 | |
• Physicians sometimes use language that seems to imply abandonment of their patients during the end-of-life decision-making process, as if withdrawal is the sole responsibility of the family, without mentioning another mode of cared [32] | |
11 | • Uneasiness in dealing with surrogate decision makerc [22] |
15 | • Negative opinion of advance directives, often perceived as not preventing unwanted aggressive treatment (because of lack of communication with relatives) and lacking a level of specificity necessary to facilitate decision-makingd [16] |
• Physicians' own ethical values regarding advance directivesd [38] | |
18 | • Physicians consider do-not-resuscitate orders paperwork, slow, and not applicable to situations related to dying at the ICUc [28] |
• Physicians are not aware of patients' preferences regarding do-not-resuscitate ordersd [23] | |
• Physicians believe that do-not-resuscitate orders should not be appliedd [36] | |
• Family dynamics and legal concerns were the most important concerns affecting physicians' decision to write or obtain a do-not-resuscitate orderd [39] | |
• The most important factor influencing do-not-resuscitate decisions was the opinion of the head of the department or the doctor in charge of the patient’s care, not the wishes of the patient and/or the patient’s familyd [46] | |
21 | • No acceptance that the patient is dying; opinion that life should be the foremost concern in end-of-life decision making and that patient’s goal of care is to survive (surgeons); physicians cannot let patients die: "They regard life at any cost to be a success" (comment physician)b [21],[28],[31],[35] |
• Conflicting opinion about prognosis, medical uncertainty and focus on narrow physiologic objectives without recognition that the condition of the patient becomes terminal, reaching a point of futility with prolongation of dying; these are barriers limiting the amount of time left for appropriate decision-makingb [15]-[17] | |
• Think that time spent with family wastes time and energy when families want continuation of aggressive treatment or when there is disagreement or extended hesitation over a decisionc [22] | |
• No appropriate communication strategy, no information-seeking, but instead arguing with patient and/or the patient’s family or avoiding discussions with them as decision-centred strategyc [30] | |
• Feeling of loss of control of referred patients and not believing in giving up on patients are reasons not to refer patients to hospiced [44] | |
• No recognition of patients’ goals of cared [23] | |
22 | • Physicians find it easier to carry on with treatment than to discuss alternative goals of carec [21] |
• Surgeons consider informed consent documentation as a contract for potentially burdensome postoperative therapy after a difficult operation (for example, transplant, neurosurgery)d [24] | |
23 | • Concerns about omission of life-sustaining treatment are larger (missing something treatable, fear of doing something wrong or limiting life-sustaining treatment for a patient who might survive) than concerns about harm of administering life-sustaining treatment (such as iatrogenic harms, prolonging dying, and treating patients against their preferences)b [17],[19] |
• Physicians' concerns about potential legal action taken by families due to forgoing life-sustaining treatment; therefore, they follow families' wishes, even after reading patients' advance directives and even when the medical staff uniformly feels that it is not medically appropriate because treatment is futilec [16],[26],[36],[39],[42] | |
• Physicians prefer their own ideas about the best interests of the patient, are more focused on medical technical parameters concerning withholding or withdrawing therapy, and continue treatment, not respecting the patient’s and/or the patient’s family’s wishes or the patient’s living will to stop treatmentc [27],[33],[34],[40] | |
• Less respect for patients' wishes by surgeons compared to other ICU physiciansc [28] | |
• Feeling of betrayal, unhappiness, disappointment and even culpability when family member confronts physician with advance directives in the setting of prolonged life-sustaining treatmentd [24] | |
• The treating physician considers death in the ICU as a personal failured [24] | |
• Physician’s distrust of the health care proxy’s motivation to request forgoing life-sustaining treatment and the family’s underlying preferencesd [25] | |
• Physician's distrust concerning the timing of the completion of the advance directived [25] | |
• Physician’s conception that medical enduring power of attorney and advance directives provide indications or guidelines rather than a decision that has to be respectedd [25] | |
• Legal concerns or disagreements with other physicians about whether it is appropriate to write a do-not-resuscitate order or withdraw treatment from patients who lack decision-making capacity and do not have a surrogate decision makerd [43] | |
• Personal values and beliefs of intensivists, more than comorbidities or the type of acute illness, are barriers to forgoing life-sustaining treatmentd [50] |
Quality indicator no. a | Barriers with respect to physicians' practice |
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General | • Competing demands for clinicians' timeb [42] |
1 | • Unavailability of attending physicians due to rotation systemsc [22] |
2 | • Hierarchy under physicians is a barrier to their solving problems within the team before talking to the patientc [22] |
• Individual physicians' lack of holistic viewsc [26] | |
7 | • Physicians do not routinely check that family members understand the information they are given and do not discuss the family’s role in decision-makingc [29] |
10 | • Low confidence in taking responsibility; physicians do not refer patients to hospice care, because the patient or the patient’s family does not accept that the patient is dyingb [44] |
15 | • Not actively recommending the creation of an advance directiveb [38] |
21 | • Low confidence in taking responsibility; the physician does not take responsibility for collaborative decision-making with the dying patient and thus leaves the patient to die as if the patient has decided when to diec [15] |
• Low confidence in taking responsibility; the physician externalizes control of decision-making to patients, their families and specialists, who they believe expect aggressive treatmentc [17] | |
• Postponing decision-making until all treatment options are exhausted, until the last moment (surgeons)c [28] | |
• No use of professional or local guidelines related to the provision of futile careb [31] | |
23 | • Lack of time and information are reasons to initiate life support, resulting in futile treatmentc [26] |
• Continuation of aggressive treatment is justified, because of lot of money is already invested in the patient, and availability of resourcesc [17] | |
• Aggressive care deemed to be appropriate because of no awareness among providers of existence of advance directive or living willb [16] | |
• Low confidence in taking responsibility; the rate of withholding and withdrawing therapy was reduced based upon family’s wishesb [35] | |
• Considering withholding and withdrawing decisions inappropriately delayedb [37] | |
• No support of an internal multidisciplinary committee or professional policies in cases involving patients who do not have decision-making capacity or a surrogateb [43] | |
• Low confidence in taking responsibility; when the patient’s family insists that everything should be done for a patient with a poor prognosis, physicians are less inclined to withdraw treatment than when the family insists on limitation of therapyb [48] | |
• Low confidence in taking responsibility; high hopes of the family and their consistent requests to the surgeons contribute to the continuation of therapy which was considered futile by at least two consultantsb [49] |