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Intensive care unit decision-making: Understanding and improving the decision-making process surrounding admission to the intensive care unit

icu

Project Summary

This project regarding critical care admissions started in February 2015 and completed in April 2018. It was funded by the NIHR's Health Services and Delivery Research programme. The research focused on the process of referral and admission decisions for intensive care and the factors that influence these decisions. Intensive care unit (ICU) admission offers potentially life-saving treatments, but is associated with burdens of distressing and invasive interventions.

Patients not admitted to ICUs are more likely to die and timely admission to the ICU has better outcomes. ICU mortality is around 30 per cent and, for those who survive ICU hospital mortality, is over 10 per cent. ICU survivors often need ongoing medical care for many years. Predicting who will benefit from ICU treatment, and who to admit, presents a difficult clinical and ethical challenge.

There are currently no national guidelines on criteria or processes for making these decisions. The limited empirical evidence suggests that:

  • There is marked variability in decision-making among clinicians
  • Non-medical factors such as age and resources influence decision-making
  • Clinicians demonstrate a prognostic pessimism that does not correlate with objective data
  • Decisions are not communicated to patients and families

This variability suggests that clinicians may be influenced by a range of different factors in their decision-making processes, which in turn raises concern about potential inequity for patients. There is a clear need to ensure that the decisions are consistent, transparent and ethically justifiable, and that clinicians and families are supported in the process.

This study:

  • Explored the current experience of clinicians and families with regard to these decisions
  • Identified the key factors that ICU consultants and outreach nurses take into account when making decisions about admission to intensive care.
  • Developed and implemented a support framework to facilitate decision-making

The project found that:

  • Decision-making processes are complex and influenced by a range of patient-related, contextual and organisational factors.

  • Good communication and relationships of respect and trust between clinical teams are essential requirements for a good decision-making process.

  • Decision-makers find it difficult to articulate and balance the burdens and benefits of the intensive care unit, and values, both implicit and explicit, influence the decision.

  • There is a perceived need for support, especially for junior doctors, and an acknowledgment that decision-making should be more transparent and ethically justifiable.

  • The decision support framework we developed was generally well received by doctors although there were some challenges and lessons were learned for future implementation initiatives.

  • Patients and families were not often involved in the decision-making process. Further research is required to understand and overcome the barriers to patient and family involvement in this crucial decision-making process

The final report has now been published and is available here

An easy read summary of the report can be downloaded here

A two page overview is available here

Dr Chris Bassford (Joint Principal Investigator)

Dr Anne-Marie Slowther (Joint Principal Investigator)