- Littlewood K.E.
- 1.Drafting. The case focused on a 78-year-old woman on Day 12 of mechanical ventilation with a relatively poor prognosis receiving prolonged mechanical ventilation for Acute Respiratory Distress Syndrome (ARDS).
- 2.Expert advisory panel. We shared the draft with an expert advisory panel consisting of clinicians and researchers from critical care medicine, critical care nursing, geriatrics, and palliative care. We conducted semistructured interviews16to identify the strengths and weaknesses of the case for studying surrogate decision making about patient values and preferences in the intensive care unit (ICU).
- 3.Case revision. We made two changes based on the expert advisory panel's feedback. First, we focused the case on whether the patient should undergo tracheostomy and percutaneous gastrostomy because these decisions involve trade-offs between deeply held values such as prolonging life, avoiding burdensome treatments, maintaining independence, and honoring spiritual beliefs.17,18,19Second, we made the patient's values more authentic to the way families talk.
- 4.Actor training. We trained two experienced medical actors who were Caucasian women in their 30s–40s to portray the patient's daughter. They studied written information about their character and learned two standardization rules: 1) do not volunteer information about the patient's values and preferences unless the clinician asks and 2) give standardized information to specific types of questions. Although families do not operate under such rules, simulation always requires calculated trade-offs with realism. We considered this trade-off acceptable for two reasons. First, empiric evidence suggests that families do not talk much about patients' values and preferences in ICU family conferences if not asked.9Second, we designed the rules to require that clinicians ask about patients' values and preferences in order for them to be discussed and to reward them for asking, allowing them to move the conversation forward toward a patient-centered treatment decision. Thus, the rules support the overarching goal of developing a method of assessing clinicians' communication skills and change in response to interventions.
- We also trained the actors not to express too much emotion, so that clinicians did not spend the whole simulation on emotional support. They practiced in a series of four hours of role play with study investigators and two hours with volunteer physicians. The role plays included feedback about following the rules, as well as their authenticity to families encountered in clinical practice.
- 5.Clinician panel. Once the actors had learned the role, we recruited 16 fellows and attendings from critical care and palliative care to pretest it. They went through the simulation procedures described in the section below on the pilot phase and provided structured feedback about how to improve it.
- 6.Case revision. We made two modifications to the case based on the clinician panel's feedback. First, we made her more emotional because she was initially so reserved that she was unrealistic compared to actual practice. Second, we reduced how much information the actors divulged in response to any single question about the patient's values to one to two statements. This addressed both physicians' sense that the actors shared more than most family members and our goal of studying how clinicians facilitate shared decision making based on an incapacitated patient's values and preferences; they would not have to use these skills if the actor provided information too freely.
|Characteristic||Development Phase N = 16% or Mean (SD)||Pilot Phase N = 50% or Mean (SD)|
|Mean age (SD)||37.4 (9.0)||39.8 (9.8)|
|% Latino or Hispanic||12||6|
|Mean years in practice (SD)||8.3 (9.3)||8.9 (8.8)|
|Area of practice|
|% Critical care||88||72|
|% Palliative care||12||28|
Feasibility of Study Procedures
|To What Extent Were the Following Similar to What You Encounter in Your Practice?||Pilot Phase Median Scale 1–10 (IQR)|
|Realism||Family conference||8 (7–10)|
|Actor portraying the family member||9 (7–10)|
|Emotions expressed||9 (8–10)|
|Discussion about the patient's values and treatment preferences||8.5 (7–10)|
|Conference room||10 (9–10)|
|Clinical information||10 (8–10)|
|Acceptability||How acceptable did you find participation overall?||9.75 (8–10)|
Feasibility of Standardizing Communication
|Error Types||N Errors||% Errors|
|Values and preferences|
|Didn't share/answered incorrectly||11||1.0|
|Didn't share/answered incorrectly||10||0.9|
|Total (1068 opportunities)||45||4.2|
Discrimination Among Physicians' Use of Communication Skills
|Communication Skills Used by Physicians||Simulation Characteristics (N = 50)|
|Elicited the patient's previously expressed values and preferences|
|Any question—n (%)||50 (100)|
|Number of questions—mean (SD, total range)||9.8 (7.3, 1–36)|
|Deliberated about how to apply the patient's values and preferences in the current situation|
|Discussed how the patient would think or feel about the current situation or possible futures|
|Any discussion—n (%)||40 (80)|
|Mean (SD, total range)||2.2 (1.8, 0–6)|
|Offered a treatment recommendation based on the patient's values and preferences|
|Any recommendation—n (%)||23 (46)|
|Number of recommendations—mean (SD, total range)||0.68 (0.94, 0–4)|
|Total communication about patients' values and preferences|
|Any question—n (%)||50 (100)|
|Number of statements—mean (SD, range)||12.7 (8.4, 1–42)|
|Association with Patient-Centeredness of Care—Spearman's rho (P-value)||0.36 (0.01)|
- Littlewood K.E.
Disclosures and Acknowledgments
Online Supplement 1. Case Patient Electronic Medical Record: Vitals, Laboratory Data, Off-Service Progress Note, and Radiologist Chest X-Ray Interpretation
|3Flowsheet Print Request|
|Patient: JEFFERSON, MARY||Printed by: PULMONARY FELLOW|
|MRN: 100004025||Date Range: m/d-1/yyyy 12:00 am to m/d/yyyy 08:00 am||Printed on: m/d/yyyy 08:00 am.|
|Temperature conversion (C)||37.3|
|Mean blood pressure||62||72||72||83||69|
|Oxygen % (FiO2)||60||60||60||60||60|
|Respiratory devices/method||Endotracheal tube||Endotracheal tube||Endotracheal tube||Endotracheal tube||Endotracheal tube|
|Flowsheet Print Request|
|Patient: JEFFERSON, MARY||Printed by: PULMONARY FELLOW|
|MRN: 100004025||Date range: m/d-1/yyyy 12:00 am to m/d/yyyy 08:00 am||Printed on: m/d/yyyy 08:00 am|
|Base excess, arterial||3|
- -COPD (baseline FEV1 48% predicted, temporarily on home O2 after an exacerbation last year)
- -s/p hysterectomy 1962.
- -Continue sedation with fentanyl
- -Delirium management with scheduled and prn zyprexa
- -Prn haldol in case agitation results in dyssynchrony/desaturation; reserve lorazepam only in case agitation does not respond to haldol
- -MICU mobility protocol
- -continue low tidal volume ventilation (6 mg/kg)
- -wean oxygen as tolerated to maintain SaO2 >88%
- -combivent, prn albuterol to manage obstruction
- -will discuss tracheostomy with daughter before consulting surgery
- -continue home ASA, statin
- -Strict I/O
- -Renally dose medications and avoid nephrotoxins
- -Colace, senna while on fentanyl gtt
- -Tube feeds at goal
- 1.Diffuse alveolar infiltrates in all lobes of both lungs, likely representing ARDS
- 2.Unchanged tubes and lines
Online Supplement 2. Exemplars of Correct Responses and Errors According to the Case Rules
|Type of Statement||Exemplar||Explanation of Case Rule/Violation|
|Values and preferences|
|Answered correctly||Physician: And was she like an independent person, or what was she like?|
Case daughter: Oh, [chuckles] fiercely independent.
|The case daughter was supposed to talk about the patient's values and preferences in response to all physician questions about them.|
|Volunteered||Physician: OK. And so you've been taking time from work to come here?|
Case daughter: Um, I have a certain amount of flexibility. So yeah, and I also want to say, I mean, we had—talking to my mom about if there ever came a time when it was too rough for her to live by herself that—how she would feel about living with us. And she welcomed that idea, she wasn't resistant to it.
|The case daughter was never supposed to talk about the case patient's values and preferences without the physician asking. Here, she volunteers the patient's values related to living independently.|
|Didn't share||Physician: Now I did want to kind of look at the big picture with you and kind of get a sense of what she's expressed to you in the past about long-term support like that, right, because if we did a tracheostomy, that would be a long-term commitment to being on the ventilator essentially.|
Case daughter: Um, you, you—so once you do that you can't ever come off that, is that what you're saying?
|Whenever the physician asked about the patient's values and preferences, the case daughter should talk about them. Here, she changed the subject to talk about treatment options.|
|Answered incorrectly||Physician: Maybe you can tell me a little bit about where things are with your mom now, what you're hearing from the doctors, how you're looking at things.|
Case daughter: Yeah, um, well, you know, she's been in here about 12 days now.
Case daughter: A long time. And, uh, this is very unexpected by all of us. And I know she's on antibiotics for the pneumonia and for the sepsis that she seemed to develop, but that's under control. And it was good news to hear that she didn't have to go on dialysis.
Physician: Yeah. Yep, yep.
Case daughter: Right? And they might have cleared up a sort of kidney infection along the way and that's good.
|The case provided details about the medical history. The case daughter was supposed to adhere to them. This was incorrect because the case patient did not have a urinary tract infection or acute kidney injury/any indication for dialysis.|
|Answered correctly||Physician: And you mentioned that you had had some conversations with her about critical care and what she would want. What kind of things had she said?|
Case daughter: Well, she said that like after what my dad had gone through, she said that like having a feeding tube for the rest of her life would not be something that she would want to have done.
|The case daughter was required to directly answer a question about what the patient would want by saying she didn't know, or that the patient would not want a tracheostomy/feeding tube.|
|Volunteered||Physician: But because of her kidneys being a little bit hurt in the process—most of the medicines are filtered through the kidneys, and some patients like her take a little bit longer to wake up. So it's expected that she will take a little longer than a younger person, and a little longer than someone with normal kidney function.|
Case daughter: Yeah, it would be really um, great to be able to talk to her about all this.
Case daughter: Um, I'm not exactly sure how … how she would feel about [sighs lightly] some of these things we were talking about.
|The case daughter was only supposed to talk about what the patient might want if the physician asked. Here, she volunteered that she didn't know how her mom would feel, which violates the rule.|
|Didn't share||Physician: And what you're telling me about what she said about your dad and watching your dad's illness, it sounds like that's not really an OK alternative or choice for her. So then the question is, what do we do if we know that this option is not OK with her, it's not an OK quality of life? Does that make sense?|
Case daughter: I guess I just wanna ask again, I mean, is there any ounce of hope … we wouldn't have to go that route?
|The case daughter was required to directly answer a question about what the patient would want by saying she didn't know, or that the patient would not want a tracheostomy/feeding tube. Here, she changed the subject to ask about prognosis and express emotions.|
|Answered incorrectly||Physician: Do you have any thoughts on whether we should go forward with the tracheostomy at this point?|
Case daughter: At this point … if there's a chance, I would think that my mom would say, “there's a chance, do it, then see what happens.”
|The case daughter was required to directly answer a question about what the patient would want by saying she didn't know, or that the patient would not want a tracheostomy/feeding tube. She could never say the patient would want a tracheostomy. She violated that rule here.|
Appendix A. Supplementary data
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