Improved shared decision making of resuscitation and ICU
In common practice, the conversation about reanimation and ICU admission is often done at the emergency department by inexperienced doctors in a stressful environment. Half of the patients did not recall these conversations. Of these patients, only 80% remembered the decision made. Two thirds experienced this conversation afterwards as being positive or normal.ref To improve this important decision and make it less stressful, a quiet and relaxing environment for patients and doctors is essential. In this project, this conversation was therefore performed before hospital admission by the general practitioner who generally knows the patient well. Future plans are to introduce this at the outpatient clinic of hospitals. To prepare patients for this conversation, a decision aid with detailed information about life sustaining treatments was provided. Special attention was given to patients with low health literacy and numeracy; explanations were presented and illustrated in an easy, understandable way. Included in the conversation were questions about ‘what matters to you?’ and about frailty. A special training program for general practitioners and their practice assistants was developed to inform them about the data that were summarized in a decision aid for healthcare professionals. This approach is tested in a pilot project in three Dutch regions. The general practitioner was paid for the extra consultations An IT-connection was made between the systems of the general practitioner and the hospitals. More than 500 patients are included so far. The scale of the project can be expanded if the pilot is successful.
By discussing topics such as reanimation and ICU admission, which is relevant for everybody, a similar method can be used for other treatment decisions with frail older patients. Awareness of the possible harms of a treatment and of the patient’s wishes is important for decision-making. Early in the Covid-19 pandemic people were called to make decisions about reanimation and ICU admission. This is seen as a lost opportunity to optimize well informed and tailored decisions and improve patient-doctor contact.
The years to come will be challenging times for health systems worldwide. An aging, frail population and technologically advanced treatments will raise healthcare costs enormously. In terms of cost and capacity, other selections should be made. The Covid-19 pandemic has shown how vulnerabilities in health systems can have profound implications on the whole care (and economic) system . Especially during times of ICU bed shortages, selections and decisions are of great importance to deliver the best quality of care considering a tight capacity. Making well informed, tailored decisions together about who could benefit from an ICU admission, probably reduces unnecessary admissions as well as undesired outcomes.
Reference; Communicatie over reanimatiebeleid in het ziekenhuis,.Marc Schluep et all.Ned Tijdschr Geneeskd. 2021;165:D5692