Decision conflict and regret among surrogate decision makers in the medical intensive care unit

Jesse J Miller; Peter Morris; D Clark Files; Emily Gower; Michael Young

doi:10.1016/j.jcrc.2015.11.023

Decision conflict and regret among surrogate decision makers in the medical intensive care unit

J Crit Care. 2016 Apr:32:79-84. doi: 10.1016/j.jcrc.2015.11.023. Epub 2015 Dec 8.

Authors

Jesse J Miller¹, Peter Morris², D Clark Files³, Emily Gower⁴, Michael Young⁵

Affiliations

¹ Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012. Electronic address: mill1628@gmail.com.
² Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012. Electronic address: pemorris@wakehealth.edu.
³ Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012. Electronic address: dfiles@wakehealth.edu.
⁴ Wake Forest School of Medicine, Department of Epidemiology and Ophthalmology, Winston Salem, NC 27012. Electronic address: egower@wakehealth.edu.
⁵ Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012. Electronic address: mpyoung@wakehealth.edu.

PMID: 26810482
DOI: 10.1016/j.jcrc.2015.11.023

Abstract

Introduction: Family members of critically ill patients in the intensive care unit face significant morbidity. It may be the decision-making process that plays a significant role in the psychological morbidity associated with being a surrogate in the ICU. We hypothesize that family members facing end-of-life decisions will have more decisional conflict and decisional regret than those facing non-end-of-life decisions.

Methods: We enrolled a sample of adult patients and their surrogates in a tertiary care, academic medical intensive care unit. We queried the surrogates regarding decisions they had made on behalf of the patient and assessed decision conflict. We then contacted the family member again to assess decision regret.

Results: Forty (95%) of 42 surrogates were able to identify at least 1 decision they had made on behalf of the patient. End-of-life decisions (defined as do not resuscitate [DNR]/do not intubate [DNI] or continuation of life support) accounted for 19 of 40 decisions (47.5%). Overall, the average Decision Conflict Scale (DCS) score was 21.9 of 100 (range 0-100, with 0 being little decisional conflict and 100 being great decisional conflict). The average DCS score for families facing end-of-life decisions was 25.5 compared with 18.7 for all other decisions. Those facing end-of-life decisions scored higher on the uncertainty subscale (subset of DCS questions that indicates level of certainty regarding decision) with a mean score of 43.4 compared with all other decisions with a mean score of 27.0. Overall, very few surrogates experienced decisional regret with an average DRS score of 13.4 of 100.

Conclusions: Nearly all surrogates enrolled were faced with decision-making responsibilities on behalf of his or her critically ill family member. In our small pilot study, we found more decisional conflict in those surrogates facing end-of-life decisions, specifically on the subset of questions dealing with uncertainty. Surrogates report low levels of decisional regret.

Keywords: Critical care; Palliative care; Surrogate decision making.

MeSH terms

Adult
Aged
Aged, 80 and over
Clinical Decision-Making*
Conflict, Psychological
Critical Care / psychology*
Critical Illness / psychology*
Emotions
Family / psychology
Female
Humans
Intensive Care Units
Male
Middle Aged
Patient Advocacy / psychology*
Pilot Projects
Prospective Studies
Resuscitation Orders / psychology
Terminal Care / psychology
Third-Party Consent
Uncertainty
Young Adult