Achieving Goals of Care Decisions in Chronic Critical Illness: A Multi-Institutional Qualitative Study

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Critical Care Medicine; Pulmonology

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BACKGROUND: Clinicians, patients, and families alike perceive a need to improve how goals of care (GOC) decisions occur in chronic critical illness (CCI) but little is currently known about this decision making process. RESEARCH QUESTION: How do intensivists from various health systems facilitate decision-making about GOC for patients with CCI? What are barriers to, and facilitators of, this decision-making process? STUDY DESIGN: AND METHODS: We conducted semi-structured interviews with a purposeful sample of intensivists from the United States and Canada using a 'mental models' approach adapted from decision science. We analyzed transcripts inductively using qualitative description. RESULTS: We interviewed 29 intensivists from six institutions. Participants across all sites described GOC decision-making in CCI as a complex, longitudinal, and iterative process that involved substantial preparatory work, numerous stakeholders, and multiple family meetings. Intensivists required considerable time to collect information on prior events and conversations, and to arrive at a prognostic consensus with other involved clinicians prior to meeting with families. Many intensivists stressed the importance of scheduling multiple family meetings to build trust and relationships prior to explicitly discussing GOC. Physician-identified barriers to GOC decision-making included one week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members or families. Potential facilitators included scheduled family meetings at regular intervals, greater interprofessional involvement in decisions, and consistent messaging from care team members. INTERPRETATION: Intensivists described a complex time and labor-intensive group process to achieve GOC decision-making in CCI. System-level interventions that improve how information is shared between clinicians and decrease logistical and relational barriers to timely and consistent communication are key to improving goals-of-care decision making in chronic critical illness.