Communicating with Surrogate Decision Makers about Incapacitated ICU Patients' Values

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DESCRIPTION (provided by applicant): Patient-centered care - defined as care that is respectful of and consistent with patients' values - is a central goal of modern medicine. Three decades of research demonstrate that incapacitated patients with serious ill- ness often receive medical care that is not patient-centered. From a public health standpoint, this issue is particularly concerning in the case of acute respiratory failure requiring mechanical ventilation because it affects 800,000 American patients per year. A growing body of evidence suggests that one important factor contributing to the problem is that clinicians inadequately elicit and incorporate incapacitated patients' values into treatment decisions. Indeed, in our preliminary research, clinicians did not ask about patients' values at all in half of ICU family conferences about treatment decisions. When they did ask, their inquiries were typically superficial. Therefore, interventions are needed to increase clinician communication about patient values to improve patient-centered decision-making. However several important gaps impede progress: 1) there currently is no efficient mechanism to train physicians to elicit and incorporate patients values into treatment decisions; 2) there is a paucity of evidence about exactly how clinicians should elicit and incorporate patients' values into life support decisions, making it difficult to identify which behaviors interventions should target; and 3) no measure exists to assess the effectiveness of interventions. This project makes the first steps toward addressing each of these three barriers. First, drawing on the established simulation infrastructure at the University of Pittsburgh, we will refine and pilot test a novel high fidelity simulation that will serve as th means to train physician's in future interventional studies. Second, we will conduct a modified Delphi study among a diverse stakeholder panel to develop consensus recommendations about how clinicians should communicate with surrogates about incapacitated patients' values. Third, we will combine the results of our preliminary data, literature review, and the Delphi into an outcome measure to allow us to quantify how clinicians elicit and incorporate incapacitated ICU patients' values into treatment decisions. This project will provide the applicant with essential training in critical care outcomes research through didactic training, intensive mentoring, experiential research, and participation in a community of learners as detailed in her training plan. It will generate critical preliminary data for a K23 application to further refine the outcom measure and to develop an intervention to improve clinician communication about incapacitated patients' values, and subsequently an R01 application to test the effectiveness of the intervention in improving patient and family outcomes.