Key elements and checklist of shared decision-making conversation on life-sustaining treatment in emergency: a multispecialty study from China

doi:10.5847/wjem.j.1920-8642.2023.076

Abstract

Abstract:

BACKGROUND: Shared decision-making (SDM) has broad application in emergencies. Most published studies have focused on SDM for a certain disease or expert opinions on future research gaps without revealing the full picture or detailed guidance for clinical practice. This study is to investigate the optimal application of SDM to guide life-sustaining treatment (LST) in emergencies.
METHODS: This study was a prospective two-round Delphi consensus-seeking survey among multiple stakeholders at the China Consortium of Elite Teaching Hospitals for Residency Education. Participants were identified based on their expertise in medicine, law, administration, medical education, or patient advocacy. All individual items and questions in the questionnaire were scored using a 5-point Likert scale, with responses ranging from “very unimportant” (a score of 1) to “extremely important” (a score of 5). The percentages of the responses that had scores of 4-5 on the 5-point Likert scale were calculated. A Kendall’s W coefficient was calculated to evaluate the consensus of experts.
RESULTS: A two-level framework consisting of 4 domains and 22 items as well as a ready-to-use checklist for the informed consent process for LST was established. An acceptable Kendall’s W coefficient was achieved.
CONCLUSION: A consensus-based framework supporting SDM during LST in an emergency department can inform the implementation of guidelines for clinical interventions, research studies, medical education, and policy initiatives.

Key words: Shared decision-making, Life-sustaining treatment, Emergency, Checklist

Shu Li, Jing Xie, Ziyi Chen, Jie Yan, Yuliang Zhao, Yali Cong, Bin Zhao, Hua Zhang, Hongxia Ge, Qingbian Ma, Ning Shen. Key elements and checklist of shared decision-making conversation on life-sustaining treatment in emergency: a multispecialty study from China[J]. World Journal of Emergency Medicine, 2023, 14(5): 380-385.

Figures/Tables 1

Table 1.

Domains and items evaluated in the Delphi process as key elements in SDM of LST

Items	The first round		The second round		Checklist
Items	Percentage of 4-5 points	Median (IQR) of Likert score	Percentage of 4-5 points	Median (IQR) of Likert score
Communication skills	100%	5 (5, 5)	100%	5 (5, 5)	√
Dress neatly, be vigorous and energetic	93%	4 (4, 5)
Give a warm welcome and use proper name etiquette	86%	4 (4, 5)
Smile, maintain eye contact, and listen attentively	90%	4 (4, 5)
Introduction of the name, title, role of hosting physician and medical team	86%	5 (4, 5)	93%	4 (4, 5)	√
Use open-ended questions to start a conversation	64%	4 (3, 5)
Pay attention to logicality	100%	5 (4, 5)
Avoid medical terminology	100%	4 (4, 5)	93%	5 (4, 5)	√
Encourage questions	86%	5 (4, 5)	93%	5 (4, 5)	√
Pay attention to problems and dissatisfaction and maintain an open attitude	86%	5 (5, 5)	93%	4 (4, 5)	√
Express gratitude at the end of the conversation	57%	4 (3, 5)
Disclosure of medical information	100%	5 (5, 5)	100%	5 (5, 5)	√
The purpose of communication is life-sustaining treatment (endotracheal intubation, mechanical ventilation, chest compression, electric defibrillation, etc.)	100%	5 (5, 5)	100%	5 (5, 5)	√
The name and rationale of diagnosis	86%	5 (4, 5)	100%	5 (4, 5)	√
Disease severity and prognosis	100%	5 (5, 5)	100%	5 (4, 5)	√
Medical suggestion of goals of care (curing, alleviating symptoms, or palliative care)	100%	5 (5, 5)	100%	5 (5, 5)	√
Explain the risks and benefits of various life sustaining treatments, alternatives, and treatment-related costs	100%	5 (5, 5)	100%	5 (5, 5)	√
Provide evidence-based medical evidence (e.g., survival rate of IHCA, 1-year survival rate of patients with mechanical ventilation in ICU, etc.)	79%	5 (4, 5)	86%	4 (4, 5)	√
Explain medical uncertainty	93%	5 (5, 5)	100%	5 (5, 5)	√
Patient autonomy and decisional assistance	100%	5 (5, 5)	100%	5 (4, 5)	√
Patient privacy protection	100%	5 (5, 5)	100%	5 (5, 5)	√
Identify the patient’s surrogate decision-maker and his/her relationship with the patient	100%	5 (5, 5)	100%	5 (5, 5)	√
Provide knowledge by explaining or using tools	86%	4 (4, 5)	86%	4 (4, 5)	√
Patient/surrogate goals of care (curing, alleviating symptoms, or palliative care)	100%	5 (4, 5)	93%	5 (5, 5)	√
Explain the differences between doctors and patients	100%	5 (5, 5)	86%	4 (4, 5)	√
Ask for the patient’s wishes directly or indirectly	100%	5 (4, 5)	86%	5 (4, 5)	√
Active inquiry of the uncertainty of decision-making, hesitation, anxiety, decision-making difficulties	100%	5 (5, 5)	100%	5 (4, 5)	√
Offer “experimental treatment cycle” scheme for difficult decision-making, that is, allow decision-making according to the situation after short-term treatment	100%	5 (4, 5)	93%	5 (4, 5)	√
Provide advice for financial support if necessary	64%	4 (3, 4)
Summary and process improvement	93%	5 (4, 5)	100%	5 (4, 5)	√
Summary and clarification, including medical decisions and conflicts in decision-making	100%	5 (4, 5)	100%	5 (4, 5)	√
Identify decision-making delay, namely, unsigned informed consent documentation	79%	4 (4, 5)
Ask the patient/surrogate for their opinions and suggestions on the communication process, and make use of a questionnaire when feasible	64%	4 (3, 5)
Follow-up for possible reversed decision during hospital stay	93%	5 (4, 5)
Documentation of shared-decision making communication	93%	5 (4, 5)	100%	5 (4, 5)	√
Feed back to the entire medical team	100%	5 (4, 5)	100%	5 (5, 5)	√
Communication skill training and continuous improvement of this list	86%	4 (4, 5)

Table 1.

References 22

1	Ouchi K, George N, Schuur JD, Aaronson EL, Lindvall C, Bernstein E, et al. Goals-of-care conversations for older adults with serious illness in the emergency department: challenges and opportunities. Ann Emerg Med. 2019; 74 (2):276-84. doi: S0196-0644(19)30003-4 pmid: 30770207
2	Schoenfeld EM, Probst MA, Quigley DD, St Marie P, Nayyar N, Sabbagh SH, et al. Does shared decision-making actually occur in the emergency department? Looking at it from the patients’ perspective. Acad Emerg Med. 2019; 26 (12):1369-78. doi: 10.1111/acem.13850 pmid: 31465130
3	Probst MA, Noseworthy PA, Brito JP, Hess EP. Shared decision-making as the future of emergency cardiology. Can J Cardiol. 2018; 34 (2):117-24.
4	Hong H, Jia H, Zeng M, Gutiérrez-Chico JL, Wang Y, Zeng X, et al. Risk stratification in acute coronary syndrome by comprehensive morphofunctional assessment with optical coherence tomography. JACC Asia. 2022; 2(4):460-72. doi: 10.1016/j.jacasi.2022.03.004 pmid: 36339358
5	Probst MA, Kanzaria HK, Schoenfeld EM, Menchine MD, Breslin M, Walsh C, et al. Shared decision-making in the emergency department: a guiding framework for clinicians. Ann Emerg Med. 2017; 70 (5):688-95. doi: S0196-0644(17)30359-1 pmid: 28559034
6	Backman WD, Levine SA, Wenger NK, Harold JG. Shared decision-making for older adults with cardiovascular disease. Clin Cardiol. 2020; 43 (2):196-204. doi: 10.1002/clc.23267 pmid: 31580493
7	Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, et al. Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. J Pain Symptom Manage. 2017; 53(5):821-32.e1. doi: 10.1016/j.jpainsymman.2016.12.331
8	George NR, Kryworuchko J, Hunold KM, Ouchi K, Berman A, Wright R, et al. Shared decision-making to support the provision of palliative and end-of-life care in the emergency department: a consensus statement and research agenda. Acad Emerg Med. 2016; 23(12):1394-402. doi: 10.1111/acem.13083 pmid: 27611892
9	Kanzaria HK, Brook RH, Probst MA, Harris D, Berry SH, Hoffman JR. Emergency physician perceptions of shared decision-making. Acad Emerg Med. 2015; 22 (4):399-405. doi: 10.1111/acem.12627 pmid: 25807995
10	Lum HD, Jones J, Matlock DD, Glasgow RE, Lobo I, Levy CR, et al. Advance care planning meets group medical visits: the feasibility of promoting conversations. Ann Fam Med. 2016; 14(2):125-32. doi: 10.1370/afm.1906 pmid: 26951587
11	Jain N, Bernacki RE. Goals of care conversations in serious illness: a practical guide. Med Clin North Am. 2020; 104 (3):375-89. doi: 10.1016/j.mcna.2019.12.001
12	Ouchi K, Lawton AJ, Bowman J, Bernacki R, George N. Managing code status conversations for seriously ill older adults in respiratory failure. Ann Emerg Med. 2020; 76 (6):751-6. doi: 10.1016/j.annemergmed.2020.05.039 pmid: 32747084
13	Hogan TM, Richmond NL, Carpenter CR, Biese K, Hwang U, Shah MN, et al. Shared decision-making to improve the emergency care of older adults: a research agenda. Acad Emerg Med. 2016; 23 (12):1386-93. doi: 10.1111/acem.2016.23.issue-12
14	Higashino M, Hiraoka E, Kudo Y, Hoshina Y, Kitamura K, Sakai M, et al. Role of a rapid response system and code status discussion as determinants of prognosis for critical inpatients: an observational study in a Japanese urban hospital. Medicine (Baltimore). 2021; 100 (32):e26856. doi: 10.1097/MD.0000000000026856
15	Légaré F, O’Connor AC, Graham I, Saucier D, Côté L, Cauchon M, et al. Supporting patients facing difficult health care decisions: use of the Ottawa Decision Support Framework. Can Fam Physician. 2006; 52:476-7. pmid: 17327891
16	Flynn D, Knoedler MA, Hess EP, Murad MH, Erwin PJ, Montori VM, et al. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med. 2012; 19(8):959-67.
17	Fan R. Self-determination vs. family-determination: two incommensurable principles of autonomy: a report from East Asia. Bioethics. 1997; 11 (3-4):309-22.
18	Schoenfeld EM, Kanzaria HK, Quigley DD, Marie PS, Nayyar N, Sabbagh SH, et al. Patient preferences regarding shared decision-making in the emergency department: findings from a multisite survey. Acad Emerg Med. 2018; 25 (10):1118-28. doi: 10.1111/acem.13499 pmid: 29897639
19	The State Council of the People’s Republic of China. Civil Code of the People’s Republic of China. Available at http://english.www.gov.cn/archive/lawsregulations/202012/31/content_WS5fedad98c6d0f72576943005.html
20	Bernacki RE, Block SD, American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014; 174 (12):1994-2003. doi: 10.1001/jamainternmed.2014.5271 pmid: 25330167
21	Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV, WHO Clinical Case Definition Working Group on Post-COVID-19 Condition. A clinical case definition of post-COVID-19 condition by a Delphi consensus. Lancet Infect Dis. 2022; 22(4):e102-e107. doi: 10.1016/S1473-3099(21)00703-9
22	Ma C, Riehm LE, Bernacki R, Paladino J, You JJ. Quality of clinicians’ conversations with patients and families before and after implementation of the Serious Illness Care Program in a hospital setting: a retrospective chart review study. CMAJ Open. 2020; 8(2):E448-E454. doi: 10.9778/cmajo.20190193

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