Communication tools for end-of-life decision-making in the intensive care unit: a systematic review and meta-analysis

Oczkowski et al. Critical Care (2016) 20:97 DOI 10.1186/s13054-016-1264-y RESEARCH Open Access Communication tools for end-of-life decision-making in the intensive care unit: a systematic review and meta-analysis Simon J. W. Oczkowski1*, Han-Oh Chung1, Louise Hanvey2, Lawrence Mbuagbaw3,4 and John J. You1,3 Abstract Background: For many patients admitted to the intensive care unit (ICU), preferences for end-of-life care are unknown, and clinicians and substitute decision-makers are required to make decisions about the goals of care on their behalf. We conducted a systematic review to determine the effect of structured communication tools for end-of-life decision-making, compared to usual care, upon the number of documented goals of care discussions, documented code status, and decisions to withdraw life-sustaining treatments, in adult patients admitted to the ICU. Methods: We searched multiple databases including MEDLINE, Embase, CINAHL, ERIC, and Cochrane from database inception until July 2014. Two reviewers independently screened articles, assessed eligibility, verified data extraction, and assessed risk of bias using the tool described by the Cochrane Collaboration and the Newcastle Ottawa Scale. Pooled estimates of effect (relative risk, standardized mean difference, or mean difference), were calculated where sufficient data existed. GRADE was used to evaluate the overall quality of evidence for each outcome. Results: We screened 5785 abstracts and reviewed the full text of 424 articles, finding 168 eligible articles, including 19 studies in the ICU setting. The use of communication tools increased documentation of goals-of-care discussions (RR 3.47, 95 % CI 1.55, 7.75, p = 0.020, very low-quality evidence), but did not have an effect on code status documentation (RR 1.03, 95 % CI 0.96, 1.10, p = 0.540, low-quality evidence) or decisions to withdraw or withhold life-sustaining treatments (RR 0.98, 95 % CI 0.89, 1.08, p = 0.70, low-quality evidence). The use of such tools was associated with a decrease in multiple measures of health care resource utilization, including duration of mechanical ventilation (MD −1.9 days, 95 % CI −3.26, −0.54, p = 0.006, very low-quality evidence), length of ICU stay (MD −1.11 days, 95 % CI −2.18, −0.03, p = 0.04, very low-quality evidence), and health care costs (SMD −0.32, 95 % CI −0.5, −0.15, p < 0.001, very low-quality evidence). Conclusions: Structured communication tools may improve documentation of EOL decision making and may result in lower resource use. The supporting evidence is low to very low in quality. Further high-quality randomized studies of simple communication interventions are needed to determine whether structured, rather than ad hoc, approaches to end-of-life decision-making improve patient-level, family-level, and system-level outcomes. Trial registration: PROSPERO CRD42014012913 Keywords: Communication, End-of-life, Ethics, Palliative care, Critical care * Correspondence: 1 Department of Medicine, McMaster University, Hamilton, ON, Canada Full list of author information is available at the end of the article © 2016 Oczkowski et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Oczkowski et al. Critical Care (2016) 20:97 Background Rationale With its advanced technology, the intensive care unit (ICU) can provide life-saving medical treatment to the sickest of patients; however, that same technology can also prolong the dying process for patients who are unlikely to survive. Furthermore, many people who are approaching the end of life (EoL), either due to advancing age or progressive disease, would opt for fewer invasive and aggressive treatments in favor of a more palliative or comfort-based approach if asked, but such preferences are often undocumented in the medical record [1]. As a result, ICU clinicians and the substitute decision-makers (SDMs) often engage in goals-of-care discussions to interpret the patient’s known values and preferences in the context of their illness, and to decide which ICU treatments would be in keeping with their wishes [2]. Given the medical and moral complexity of such discussions, and the need to conduct them under acute, often stressful conditions, many communication tools (including decision aids, structured meeting plans, and educational interventions) have been developed in order to assist SDMs and clinicians with EoL decision-making. However, there remains uncertainty as to whether the use of structured communication tools for EoL decisionmaking is superior to usual care. Therefore, we conducted a systematic review of the medical literature to determine the impact of communication tools for EoL decision-making in the ICU on the following outcomes: the number and quality of EoL discussions between SDMs and healthcare providers (HCPs); the documentation of code status; and decisions to withdraw or withhold life-sustaining treatments. Methods Protocol and registration The protocol for this review is available in the PROSPERO registry (http://www.crd.york.ac.uk/PROSPERO/ display_record.asp?ID=CRD42014012913). Eligibility criteria We included randomized controlled trials (RCTs) or prospective observational studies with a control group (including pre-post studies in which participants acted as their own control) published as articles in peerreviewed journals, restricted to the English language. To be eligible for this review, studies must have included patients over the age of 18 years, and evaluated a communication tool to assist in EoL decision-making in comparison to a control group. For our study, we defined a communication tool as any intervention designed to directly assist individual patients and SDMs in decision-making, or their clinicians Page 2 of 19 to better facilitate the EoL decision-making process. This included traditional decision aids in any format (paper, video, computer, etc.), and other structured approaches to assisting decision-making, including organized meeting plans, consultation with services for the purpose of assisting with decision-making (e.g., ethics or palliative care), and educational interventions on EoL care options. Interventions designed solely for informationsharing (e.g., breaking bad news, providing emotional support) were excluded, because although such interventions may affect decisions at the EoL, it is not their explicit purpose to do so (Table 1). Communication tools for ICU settings are dis (...truncated)