Interventions to Improve Surrogate Decision-Making in Intensive Care Units: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
CCCF ePoster library. Bibas L. Nov 7, 2018; 233383; 16 Disclosure(s): No disclosures.
Dr. Lior Bibas
Dr. Lior Bibas
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Abstract
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Introduction: It is uncertain whether targeted interventions to improve surrogate decision-making in intensive care units (ICUs) reduce non-beneficial treatment and improve surrogate decision-maker (SDM) comprehension, satisfaction, and related outcomes.  Several randomized clinical trials (RCTs) have observed inconsistent results. 

 

Objective: We performed a systematic review and meta-analysis to assess the efficacy of such interventions and to identify key components of successful interventions.

 

Methods: We searched OVID versions of MEDLINE, EMBASE, Ovid Nursing Database, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews, and PubMed, for potentially relevant studies. We included RCTs that included outcomes of interest in three categories: (1) patient centered (mortality, length of stay [LOS], use of life-sustaining therapies [mechanical ventilation, vasopressors, nutritional support]); (2) SDM -centered (comprehension, change in decision on goals of care, development of psychological comorbidities, satisfaction with care); and (3) resource utilization (cost of care, health care professional use).  Data were pooled using random effects meta-analysis to account for potential inter-study heterogeneity (RevMan). Binary outcomes were summarized as risk ratios (RR) and continuous outcomes as mean differences (MD), with 95% confidence intervals (CI). Heterogeneity was assessed using the I2 measure. Data from cluster RCTs was adjusted for design effect using their respective Intracluster Correlation Coefficient.

 

Results: After screening 3735 citations, 13 RCTs met inclusion criteria. Interventions were categorized as: healthcare professional-led (n=6), ethics consultation (n=3), palliative care consultation (n=2) and media (n=2). Meta-analysis revealed no difference in mortality (RR 1.03; 95% CI 0.98-1.08; I2=0%; 10 RCTs) or ICU LOS among all patients (MD –0.79 days; 95% CI -2.33 to 0.76; I2=0; 6 RCTs). There was however a significant reduction in ICU LOS among non-survivors (MD -2.11 days; 95% CI -4.16 to -0.07; I2=32%; 8 RCTs). There was no difference in satisfaction with care and conflicting results regarding psychological comorbidities (i.e. anxiety, depression and post-traumatic stress disorder). Only two trials showed improvements in comprehension with the intervention. Five trials reported on resource utilization, and only one nurse-led intervention showed a significant reduction in costs. Given the observed diversity of interventions and outcomes, it was not possible to determine key components of SDM interventions more likely to improve outcomes.

 

Conclusion: Diverse interventions to improve surrogate decision-making in ICU reduced ICU in deceased patients only. They did not effect mortality or ICU LOS in all patients. They also did not consistently reduce psychological comorbidities in family members or improve satisfaction with care.  Future studies are needed to better understand the complex processes related to surrogate decision-making to improve both patient-centered and family-centered outcomes.


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