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Critical Care
Published in: Critical Care 1/2020

Open Access 01-12-2020 | Living Will | Research

Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment

Authors: Margot Smirdec, Mercé Jourdain, Virginie Guastella, Céline Lambert, Jean-Christophe Richard, Laurent Argaud, Samir Jaber, Kada Klouche, Anne Medard, Jean Reignier, Jean-Philippe Rigaud, Jean-Marc Doise, Russell Chabanne, Bertrand Souweine, Jeremy Bourenne, Julie Delmas, Pierre-Marie Bertrand, Philippe Verdier, Jean-Pierre Quenot, Cecile Aubron, Nathanael Eisenmann, Pierre Asfar, Alexandre Fratani, Jean Dellamonica, Nicolas Terzi, Jean-Michel Constantin, Axelle Van Lander, Renaud Guerin, Bruno Pereira, Alexandre Lautrette

Published in: Critical Care | Issue 1/2020

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Abstract

Background

There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists.

Methods

We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients’ characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD).

Results

A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p < 0.001). High inter-intensivist variability did not change with ADs (RSD: 0.56 (round 1) vs 0.46 (round 2), p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain.

Conclusions

ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist’s decision took priority. Further research is needed to improve the matching of the physicians’ decision with the patient’s wishes.
Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://​clinicaltrials.​gov/​ct2/​show/​NCT03013530.
Appendix
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Metadata
Title
Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment
Authors
Margot Smirdec
Mercé Jourdain
Virginie Guastella
Céline Lambert
Jean-Christophe Richard
Laurent Argaud
Samir Jaber
Kada Klouche
Anne Medard
Jean Reignier
Jean-Philippe Rigaud
Jean-Marc Doise
Russell Chabanne
Bertrand Souweine
Jeremy Bourenne
Julie Delmas
Pierre-Marie Bertrand
Philippe Verdier
Jean-Pierre Quenot
Cecile Aubron
Nathanael Eisenmann
Pierre Asfar
Alexandre Fratani
Jean Dellamonica
Nicolas Terzi
Jean-Michel Constantin
Axelle Van Lander
Renaud Guerin
Bruno Pereira
Alexandre Lautrette
Publication date
01-12-2020
Publisher
BioMed Central
Keyword
Living Will
Published in
Critical Care / Issue 1/2020
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-020-03402-7

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