Impact of advance directives on factors involved in the decision-making in ICU

Abstract : Introduction: Physicians do not know how to follow the patients’ wishes when they are unable to express themselves. We assessed the impact of Advances Directives (AD) and how they have been written on the physician’s decisions. Methods: A multicentre, prospective, interventional, simulation study was carried out. Height patients were recruited and wrote AD after receiving clear and complete information by video and interview with one ICU physician. Two simulation scenarios including 10 questions about ICU admission and situations of withholding/withdrawing therapies using the patients’ characteristics were submitted to ICU physicians from 28 French ICU, in three rounds (R): simulation without knowledge of the patient’s AD (R1), with these AD (R2) and with these AD and the knowledge of how they were carried out (R3). Results: The preliminary results were performed on data of 82 physicians. The variability betweenphysicians themselves was high. Among the 80 questions of R1, there were 40, 23 and 17 questions with an agreement > 80%, 80-60% and <60% respectively. The AD significantly decreased the number of questions with an agreement > 80%, and increased the number of questions with an agreement <60% (p<0.001). There was no difference between the rounds 2 and 3 (p=0.6). Few physicians’ characteristics were associated with the inter-individual variability. The intra-individual variability between R1 and R2 was very high and the AD were significantly associated with this variability after adjustment on characteristics of the physicians and the patients. It is relevant to notice that the knowledge of how AD were carried out has a very low impact on the physicians’ decisions. Conclusion: The AD have a major impact on the physicians’ decisions for admission, withholding and withdrawing therapies decisions and increase the inter-individual variability but not the knowledge of how these AD have been written. It might be a limit of the autonomous model.
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Margot Smirdec. Impact of advance directives on factors involved in the decision-making in ICU. Life Sciences [q-bio]. 2018. ⟨dumas-02127471⟩

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