Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment - AutomédiCation Conciliation Pharmaceutique PatienT
Article Dans Une Revue Critical Care Année : 2020

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

1 CHU Clermont-Ferrand
2 RTD - Recherche translationnelle sur le diabète - U 1190
3 Service Biostatistiques, Télématiques, Traitement de l’image [CHU Clermont-Ferrand]
4 Service d'Anesthésie et de Soins Intensifs [Hôpital de la Croix-Rousse - HCL]
5 CREATIS - Centre de Recherche en Acquisition et Traitement de l'Image pour la Santé
6 MYRIAD - Modeling & analysis for medical imaging and Diagnosis
7 Hôpital Edouard Herriot [CHU - HCL]
8 PhyMedExp - Physiologie & médecine expérimentale du Cœur et des Muscles [U 1046]
9 CHRU Montpellier - Centre Hospitalier Régional Universitaire [Montpellier]
10 Hôtel-Dieu de Nantes
11 Centre hospitalier de Dieppe
12 Centre Hospitalier Chalon-sur-Saône William Morey
13 TIMONE - Hôpital de la Timone [CHU - APHM]
14 Centre Hospitalier Rodez
15 Centre Hospitalier de Cannes
16 Hôpital de Montluçon
17 CHU Dijon - Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand
18 CHRU Brest - Centre Hospitalier Régional Universitaire de Brest
19 UNICANCER/CJP - Centre Jean Perrin [Clermont-Ferrand]
20 CHU Angers - Centre Hospitalier Universitaire d'Angers
21 AP-HP - Hopital Saint-Louis [AP-HP]
22 CHU Nice - Centre Hospitalier Universitaire de Nice
23 CHUGA - Centre Hospitalier Universitaire [CHU Grenoble]
24 CHU Pitié-Salpêtrière [AP-HP]
25 ACCePPT - AutomédiCation aCcompagnement Pluriprofessionnel PatienT
26 NEURO - Laboratoire de Neurosciences Intégratives et Cliniques - UFC (UR 481)
27 LMGE - Laboratoire Microorganismes : Génome et Environnement
Virginie Guastella
Anne Medard
  • Fonction : Auteur
Jean-Philippe Rigaud
  • Fonction : Auteur
  • PersonId : 891933
  • IdRef : 085645052
Pierre Asfar
Jean Dellamonica

Résumé

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.
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hal-03040555 , version 1 (02-06-2021)

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Margot Smirdec, Mercé Jourdain, Virginie Guastella, Céline Lambert, Jean-Christophe Richard, et al.. Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment. Critical Care, 2020, 24 (1), pp.672. ⟨10.1186/s13054-020-03402-7⟩. ⟨hal-03040555⟩
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