Joanna L. Hart

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

Objective: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. Methods: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development. Results: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice. Conclusions: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

Perceptions of organ donation after circulatory determination of death among critical care physicians and nurses: a national survey.

Objective:We sought to identify factors related to critical care physicians’ and nurses’ willingness to help manage potential donors after circulatory determination of death, and to elicit opinions on the presence of role conflict in donors after circulatory determination of death and its impact on end-of-life care. Design and SettingRandomized trial administered by Web or post of four donors after circulatory determination of death vignettes. Response rates were 31.0% and 44.3%, respectively. Subjects:Two thousand two hundred and six academic intensive care unit physicians and 988 intensive care unit nurses in the United States. Measurements and Main Results:Majorities of intensive care unit physicians (72.5%; 95% confidence interval 69.2–75.9) and nurses (74.3%; 95% confidence interval 70.2–78.5) believed they should help manage potential donors after circulatory determination of death. 14.7% (95% confidence interval 12.0–17.4) of physicians and 14.3% (95% confidence interval 11.0–17.6) of nurses believed that management of donors after circulatory determination of death would create professional role conflicts. 33.8% (95% confidence interval 30.0–37.4) of physicians and 55.1% (95% confidence interval 50.3–59.7) of nurses believed that preserving opportunities for donors after circulatory determination of death could improve end-of-life care. More favorable views of donors after circulatory determination of death were provided by clinicians randomly assigned to vignettes depicting donors with previously denoted preferences for organ donation; similar effects were not introduced by vignettes in which surrogates actively initiated donation discussions. Conclusions:These findings suggest that critical care physicians and nurses are generally supportive of managing donors after circulatory determination of death, particularly when patients were registered organ donors. However, minorities of clinicians harbor concerns regarding conflicts of interest, and many are uncertain of the practice’s impact on end-of-life care.

Default options in the ICU: widely used but insufficiently understood.

Purpose of reviewDefault options dramatically influence the behavior of decision makers and may serve as effective decision support tools in the ICU. Their use in medicine has increased in an effort to improve efficiency, reduce errors, and harness the potential of healthcare technology. Recent findingsDefaults often fall short of their predicted influence when employed in critical care settings as quality improvement interventions. Investigations reporting the use of defaults are often limited by variations in the relative effect across sites. Preimplementation experiments and long-term monitoring studies are lacking. SummaryDefaults in the ICU may help or harm patients and clinical efficiency depending on their format and use. When constructing and encountering defaults, providers should be aware of their powerful and complex influences on decision making. Additional evaluations of the appropriate creation of healthcare defaults and their resulting intended and unintended consequences are needed.

The surprising costs of silence: Asymmetric preferences for prosocial lies of commission and omission

Across 7 experiments (N = 3883), we demonstrate that communicators and targets make egocentric moral judgments of deception. Specifically, communicators focus more on the costs of deception to them—for example, the guilt they feel when they break a moral rule—whereas targets focus more on whether deception helps or harms them. As a result, communicators and targets make asymmetric judgments of prosocial lies of commission and omission: Communicators often believe that omitting information is more ethical than telling a prosocial lie, whereas targets often believe the opposite. We document these effects within the context of health care discussions, employee layoffs, and economic games, among both clinical populations (i.e., oncologists and cancer patients) and lay people. We identify moderators and downstream consequences of this asymmetry. We conclude by discussing psychological and practical implications for medicine, management, behavioral ethics, and human communication.

Perspectives on using decision-making nudges in physician-patient communications

Patients engaging in shared decision making must weigh the likelihood of positive and negative outcomes and deal with uncertainty and negative emotions in the situations where desirable options might not be available. The use of “nudges,” or communication techniques that influence patients’ choices in a predictable direction, may assist patients in making complex decisions. However, nudging patients may be perceived as inappropriate influence on patients’ choices. We sought to determine whether key stakeholders, physicians, and laypersons without clinical training consider the use of nudges to be ethical and appropriate in medical decision making. Eighty-nine resident-physicians and 336 Mechanical-Turk workers (i.e., non-clinicians) evaluated two hypothetical preference-sensitive situations, in which a patient with advanced cancer chooses between chemotherapy and hospice care. We varied the following: (1) whether or not the patient’s decision was influenced by a mistaken judgment (i.e., decision-making bias) and (2) whether or not the physician used a nudge. Each participant reported the extent to which the communication was ethical, appropriate, and desirable. Both physicians and non-clinicians considered using nudges more positively than not using them, regardless of an initial decision-making bias in patients’ considerations. Decomposing this effect, we found that physicians viewed the nudge that endorsed hospice care more favorably than the nudge that endorsed chemotherapy, while non-clinicians viewed the nudge that endorsed chemotherapy more favorably than the nudge that endorsed hospice care. We discuss implications and propose exploring further physicians’ and patients’ differences in the perception of nudges; the differences may suggest limitations for using nudges in medical decisions.

Are Demographic Characteristics Associated with Advance Directive Completion? A Secondary Analysis of Two Randomized Trials

Preferences for future medical treatments may be documented in a legal document known as an advance directive (AD). Despite national efforts to promote AD completion, men, blacks, and those with less education less frequently complete ADs. However, it remains unclear whether such groups differ in their willingness to complete ADs or have different opportunities to do so. The latter would suggest disparities in access to advance care planning. We sought to elucidate this key distinction by assessing associations between demographic characteristics and AD completion within two randomized controlled trials (RCTs) that presented uniform opportunities to participants who may be targeted for AD completion.

The Surprising Costs of Silence: Asymmetric Preferences for Prosocial Lies of Commission and Omission

Across seven experiments (N = 3883), we demonstrate that communicators and targets make egocentric moral judgments of deception. Specifically, communicators focus more on the costs of deception to them – e.g., the guilt they feel when they break a moral rule – whereas targets focus more on whether deception helps or harms them. As a result, communicators and targets make asymmetric judgments of prosocial lies of commission and omission: Communicators often believe that omitting information is more ethical than telling a prosocial lie, whereas targets often believe the opposite. We document these effects within the context of healthcare discussions, employee layoffs, and economic games, among both clinical populations (i.e., oncologists and cancer patients) and lay people. We identify moderators and downstream consequences of this asymmetry. We conclude by discussing psychological and practical implications for medicine, management, behavioral ethics, and human communication.