Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment
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
Affiliations
Margot Smirdec
Department of Anaesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand
Mercé Jourdain
INSERM U1190, CHU Lille, Department of Critical Care Medicine, Roger Salengro Hospital, Univ. Lille
Virginie Guastella
Palliative Care Unit, Louise Michel Hospital, University Hospital of Clermont-Ferrand
Céline Lambert
Biostatistics Unit (DRCI), University Hospital of Clermont-Ferrand
Jean-Christophe Richard
Medical Intensive Care Unit, La Croix Rousse Hospital, University Hospital of Lyon
Laurent Argaud
Medical Intensive Care Unit, Edouard Herriot Hospital, University Hospital of Lyon
Samir Jaber
Department of Anaesthesiology and Critical Care Medicine, Saint Eloi Hospital, University Hospital of Montpellier
Kada Klouche
Medical Intensive Care Unit, Lapeyronnie Hospital, University Hospital of Montpellier
Anne Medard
Cardiac Surgery Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Montpied Hospital, University Hospital of Clermont-Ferrand
Jean Reignier
Medical Intensive Care Unit, Hotel-Dieu Hospital, University Hospital of Nantes
Jean-Philippe Rigaud
Intensive Care Unit, Pasteur Hospital, Hospital of Dieppe
Jean-Marc Doise
Intensive Care Unit, Morey Hospital, Hospital of Chalon-Sur-Saône
Russell Chabanne
Neurocritical Care Unit, Department of Anaesthesiology and Critical Care Medicine, Montpied Hospital, University Hospital of Clermont-Ferrand
Bertrand Souweine
Medical Intensive Care Unit, Montpied Hospital, University Hospital of Clermont-Ferrand
Jeremy Bourenne
Emergency Intensive Care Unit, La Timone Hospital, University Hospital of Marseille
Julie Delmas
Intensive Care Unit, Puel Hospital, Hospital of Rodez
Pierre-Marie Bertrand
Intensive Care Unit, Veil Hospital, Hospital of Cannes
Philippe Verdier
Intensive Care Unit, Hospital of Montluçon
Jean-Pierre Quenot
Medical Intensive Care Unit, Mitterrand Hospital, University Hospital of Dijon
Cecile Aubron
Medical Intensive Care Unit, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale
Nathanael Eisenmann
Intensive Care Unit, Centre Jean Perrin
Pierre Asfar
Medical Intensive Care Unit, Larrey Hospital, University Hospital of Angers
Alexandre Fratani
Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Saint-Louis Hospital, Assistance Publique Hopitaux de Paris
Jean Dellamonica
Medical Intensive Care Unit, l’Archet Hospital, University Hospital of Nice
Nicolas Terzi
Medical Intensive Care Unit, Michallon Hospital, University Hospital of Grenoble
Jean-Michel Constantin
GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University
Axelle Van Lander
UPU ACCePPt, Université Clermont Auvergne
Renaud Guerin
Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand
Bruno Pereira
Biostatistics Unit (DRCI), University Hospital of Clermont-Ferrand
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 .
