- Having a primary care provider (PCP) present to guide shared decision-making in the intensive care unit (ICU) is helpful in improving patient and family satisfaction and enhancing the ICU experience, according to recent data presented in the Journal of the American Board for Family Medicine.
The study sought to assess the changing landscape of the ICU, according to the researchers out of Yale School of Medicine. The ICU is currently shifting toward hospital teams led by intensivists, or providers who specialize in ICU cases. These models, called non-open, usually exclude outside providers such as long-term PCPs.
However, these models may pose some issues for building patient and family trust during shared decision-making, the researchers suggested.
“Modern, non-open ICU models—in which an intensivist is primarily responsible for admitted patients—do run the risk of ‘disenfranchising’ patients' longstanding PCPs in certain situations, especially if communication among services is not prioritized,” the team pointed out.
“An example situation may be one where a shared decision regarding acceptable future quality of life needs to be made between a medical team and a surrogate for an ICU patient who lacks decision making capacity and whose prognosis for future survival or functional outcome is likely poor,” the researchers added.
A PCP, who in many cases may have treated a patient for several years, is in a unique position to apply its knowledge of patient wishes to shared decision-making.
The researchers deployed the Family Satisfaction in the ICU 24 survey to assess whether PCP contributions to shared decision-making improved family satisfaction with care. Nearly 270 family members of neuroscience ICU patients responded to the survey, answering an overall ICU satisfaction question as well as individual survey items.
The team compared survey answers between family members who did and did not include a PCP during shared decision-making.
In all, one in five families reported PCP involvement with ICU decisions, the researchers found.
There were no statistically significant differences in overall ICU satisfaction among any of the families, the researchers reported. However, there were differences when looking at individual survey items, specifically satisfaction with family inclusion during ICU decision-making and control over patient care.
“On closer examination of the individual item responses within the standardized survey, we found that family members who reported PCP involvement in medical decision making were more likely to be completely satisfied specifically with their own inclusion in the decision-making process and control over care of the patient than those families who reported that the patient's PCP was not involved,” the researchers explained.
About three-quarters of families reported being completely satisfied with their own involvement in ICU decisions when their PCP was present, compared to 61 percent of patients who did not have the PCP present. Seventy-three percent of families reported complete satisfaction with control over care when the PCP was present during decisions, compared to 56 percent of families who did not work with a PCP.
Understanding family preferences for ICU shared decision-making is essential because families are often faced with difficult care decisions. Those decisions, coupled with the emotional trauma of having a family member in the ICU, makes it difficult for family members to easily engage with the healthcare system.
“In this sense, PCPs may play a more important role for patients admitted to the ICU than in other hospital units because their longitudinal relationships with their patients can give them unique perspectives regarding patient values and preferences when uncertainty exists in critical situations (especially when patients themselves lack decision making capacity),” the researchers suggested.
“PCPs may also provide reassurance and confidence in the ICU team for families meeting inpatient clinicians for the first time and still building trust,” the team continued.
As healthcare organizations shift ICU staffing models, the researchers recommend leaders consider the patient and family experience. Including PCPs in care teams, especially during shared decision-making, may help improve the family experience with care and put family members at ease during a difficult period.
“Based on the data from the individual items in our survey, we do conclude that PCP involvement in medical decision making may be associated with improved family satisfaction with several specific components of the shared decision making process,” the researchers concluded.
“Future studies may test proactive interventions designed to encourage PCP involvement in the ICU to increase family satisfaction with shared decision making. As this study demonstrates, these studies will need to consider carefully the specific survey instruments and individual questions that will be used to assess outcomes.”