Background
Each year, half a million adults 50 years or above suffer injury from a fall or other traumatic event.1 2 Older adults fare far worse than younger patients with similar injuries due to chronic comorbid conditions and reduced physiological reserve. As such, traumatic injury is often a preterminal event, with 20% in-hospital and 40% 1-year mortality.3 Treatment for traumatic injury frequently involves burdensome treatments (like invasive surgical procedures or prolonged life support) that may be inconsistent with patients’ preferences and goals.4–6 This disconnect between patients’ priorities and the treatments received can lead to conflict in the intensive care unit (ICU), specifically interpersonal conflict among clinicians (eg, between nurses and surgeons) and with patients’ loved ones (eg, between surrogate decision-makers and the trauma ICU team) during treatment discussions.7 8 Moreover, overtreatment at the end of life (EOL) prolongs dying and contributes US$44 billion annually in the USA to healthcare costs.9 A communication intervention that facilitates the articulation of patient priorities could reduce unwanted invasive procedures and clarify patients’ long-term goals, benefiting patients, loved ones, clinicians and healthcare systems.10
The Best Case/Worst Case-ICU tool
We developed a communication intervention called Best Case/Worst Case-ICU that uses scenario planning, that is, a narrative description of plausible futures, to support decision-making and facilitate dialogue among patients, their loved ones and the trauma team. Typically, in accordance with standards for informed consent, clinicians present risks as discrete complications for isolated physiologic systems (eg, a 50% chance of kidney failure) or the binary outcome of mortality (eg, a 40% chance of survival).11 Because this language does not describe how a patient might experience treatments or the expected downstream outcomes, such as predictable changes in functional status, prolonged recovery or need for long-term care in a nursing home, patients and families may struggle to anticipate and account for the consequences of serious injury and make treatment decisions accordingly. Scenario planning provides an alternative strategy for managing uncertainty that is in distinct contrast to emphasising isolated risks or discrete treatment effects. Instead, scenario planning generates multiple plausible futures, prompting decision-makers to consider causal relationships and visualise a range of outcomes based on sound analysis of the present.12
We designed the Best Case/Worst Case-ICU tool to help visualise uncertainty, illustrate the interplay between major events and prognosis and describe how patients might experience the various treatments received along the course of care. By using a graphical aid to illustrate ‘what we are hoping for’, ‘what we are worried about’,13 and the evolution of the patient’s story or clinical course over time, including setbacks and improvements, the tool aims to keep everyone (clinicians, patients and loved ones) well informed. The tool facilitates clinician delivery of critical prognostic information over the longitudinal course of care, allowing subsequent treatment decisions, for example, additional operations or prolonged mechanical ventilation, to be made within the context of the patient’s overall health status and goals. Ultimately, this tool alerts patients and families to the life-limiting nature of serious injury and provides valuable insight as they consider whether comfort-focused strategies might better support their care needs.
We designed the tool to fit the pace of busy trauma ICU rounds. The trauma team collaboratively completes the graphical aid during the summative systems-based review daily for each patient (figure 1). With usual care, a clinician (typically a surgical resident) lists each physiologic system, that is, neuro, cardiac, pulmonary, etc, or individual medical problems with an assessment and plan for each. When using the tool, they add ‘outlook’, that is, the best-case scenario, at the end. While the attending physician or fellow generates this story, another team member records it on the graphical aid. The worst-case scenario is modified as needed but does not typically require daily updating. The graphical aid is posted in the patient’s room, where loved ones and clinicians can use it to recall what to expect, visualise uncertainty and see how things change over the patient’s course of care.
Example of the Best Case/Worst Case-ICU graphical aid. On each day of a patient’s ICU stay, the trauma team uses a preprinted graphical aid to review major events from the previous 24 hours and describe the patient’s overall health trajectory. On the graphical aid, each ICU day corresponds to a column, and the range of possible scenarios, that is, stories describing how this new injury could play out over time, are designated on a vertical line. A star distinguishes the ‘best-case scenario’ and a box designates the ‘worst-case scenario’. Each day, the trauma team will record any new major events at the top of the column. The star is moved based on how a new event, like a diagnosis of pneumonia or an improvement in neurological function after a stroke, changes the best-case scenario. Over time, the placement of the star goes up or down depending on how these events change the patient’s overall story. Arrows may be used to denote information is carried over from the previous day. SNF, skilled nursing facility.
The daily stories and the graphical aid provide support and perspective for everyone involved in the care of the patient. If the patient clinically improves, their loved ones are primed for the road to recovery. If the patient worsens, their loved ones will be prepared, and the gravity of the patient’s illness will not come as a surprise. Important decisions, such as proceeding with an operation or continuing mechanical ventilation, can be made within the context of the patient’s overall health trajectory. We hypothesise that this will lead to improved communication in the ICU, and patients will receive care that better aligns with their health goals. We theorise this will reduce interpersonal ICU conflict that contributes to clinician burn-out and moral distress.
This post was originally published on https://bmjopen.bmj.com