Press Room: Press Releases

Shared Decision-Making Making Inroads in French ICUs

(DES PLAINES, Ill., September 9, 2004) -French ICU patients and their families may want increased involvement in medical decision-making similar to that practiced in North America, according to an article in the September issue of Critical Care Medicine.

Recently an international consensus conference in end-of-life care reviewed decision-making models to bring consensus to both sides of the Atlantic. The conference, the International Consensus Conference on End-of-Life Issues in the ICU, concluded that shared decision-making should be the primary method for medical decisions in the ICU. The conference's executive summary was published in the August issue of Critical Care Medicine, and the proceedings were published in the May issue of Intensive Care Medicine.

"I am the director of a group of researchers working to improve the effectiveness of information provided to family members of ICU patients. We are trying to empower the family members who are interested in sharing in the decision making process" said lead author Elie Azoulay, M.D., Ph.D., of the Service de Reanimation Medicale, Hospital Saint-Louis, Paris.

The researchers studied 2,754 ICU staff members, 544 family members, and 357 patients hospitalized in 78 French ICUs to evaluate the opinions of ICU staffs and family members regarding family participation in treatment decisions. Family members typically do not participate in medical decision making in France.

The researchers found that most ICU staff members - 91% of physicians and 83% of nonphysician ICU staff - thought that ICU decision making should be offered to families, while less than half (39%) had actually involved family members in treatment decisions. About half (47%) of the family members wanted to share in decision-making, but few (15%) actually did. A section of the study recorded the families' opinions and experiences in shared medical decision-making. Many (73%) of the family members were anxious and some (35%) were depressed.

The investigators conclude that ICU staff members should gauge the degree of autonomy that families want and strive to identify practical and psychological obstacles that may limit their ability to participate in shared decision-making.

Dr. Azoulay expects that French ICUs will offer more shared decision-making in the future. "We are moving toward more autonomy with our patients and their families," he explains. "But at the same time we are also keeping our neo-paternalism. We will give patients the opportunity to decide but we will not hide our convictions."

"We are involving more and more family members in end-of-life decisions," comments Dr. Azoulay. "We perform family conferences to assess their wishes. At the same time, we also have learned to respect the wishes of family members who do not wish to participate in shared decision making."

The ICU staff members who opposed shared decision making reported that they believed that asking family members to share in decision making would add to their distress and family members may not make decisions consonant with the patient's wishes. Most of the family members who did not wish to participate in decision making felt their participation was unnecessary because the ICU made the best possible decisions.

Two accompanying editorials address the new era of medical decision-making. Editorialist Mitchell M. Levy, M.D., professor of medicine at Brown University in Providence, RI, says that more often than not patients and families welcome the advice of the ICU team. Shared decision-making is more demanding for ICU clinicians because it requires time, genuine communication and a commitment to share uncertainty with families. "During times of crisis, when medical decision-making is most difficult, the autonomy model may place an undue burden on families," comments Levy.

"Through this partnership, patients' preferences can be identified, the anxiety of families facing terrible decisions can be lessened, and physicians can have the appropriate input in the use of life-sustaining therapies in the face of complex illness," Levy concludes. "It is time for us to embrace this model and move it forward in an effort to alleviate suffering during times of critical illness."

"The pendulum is moving in both directions," says Judy E. Davidson, RN, MS, CCRN, FCCM, in an accompanying editorial. "Paternalistic nations are moving towards shared decision making. Those who have executed pure autonomous models have realized the pitfalls of this extremist approach and are now shifting back towards a more conservative and collaborative shared decision-making model. In time there is hope that a universally adopted method of information sharing and decision-making will blossom." Ms. Davidson is a clinical nurse specialist at Pomerado Hospital in Poway, Calif.

"International studies of ethics, such as the one published by Dr. Azoulay and his colleagues, allow a world-wide dialogue regarding the best methods to handle patient/family communication during this highly stressful time in a patient's medical care," said Joseph E. Parrillo, M.D., editor-in-chief of Critical Care Medicine. "Everyone learns from this dialogue."

Critical Care Medicine is the official journal of the Society of Critical Care Medicine. It is the premier peer-reviewed, scientific publication in critical care medicine. Each issue presents critical care practitioners with clinical breakthroughs that lead to better patient care, the latest news on promising research, and advances in equipment and techniques.

For more information, contact Thomas Joseph, MPS, CAE at (847) 827-7282 or tjoseph@sccm.org.

The Society of Critical Care Medicine is the leading professional organization dedicated to ensuring excellence and consistency in the practice of critical care medicine. With more than 11,000 members worldwide, the Society is the only professional organization devoted exclusively to the advancement of multiprofessional intensive care through excellence in patient care, professional education, public education, research and advocacy. Members of the Society include intensivists, critical care nurses, critical care pharmacists, clinical pharmacologists, respiratory care practitioners and other professionals with an interest in critical care, which may include physician assistants, social workers, dieticians, and members of the clergy.

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