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Population Preferences for Treatments When Critically Ill: A Discrete Choice Experiment

Abstract

Background

Many patients in the intensive care unit are too unwell to participate in shared decision making or have not previously documented their wishes. In these situations, understanding the values of the general population could help doctors provide appropriate guidance to surrogate decision makers.

Methods

Using a discrete choice experiment design, we conducted an online survey using an Australian panel. Participants were asked about their willingness to accept treatments, faced with a variety of possible outcomes and probabilities (low, moderate or high). The outcomes were across four domains: loss of functional autonomy, pain, cognitive disability and degree of burden on others. Demographic details, prior experience of intensive care unit and current health conditions were also collected. Data were analysed using logistic regression, predicting whether respondents choose to continue active treatment or not.

Results

Nine hundred and eighty-four respondents, representative of age and sex completed the web-based survey. With the increasing likelihood of negative post-intensive care unit sequelae, there was a higher probability of the respondent preferring to stop ongoing active treatment, with the largest coefficients being on caring assistance and the need for full-time residential care. Those who identified as very religious, were younger or who had children under 5 years of age were more likely to choose to continue active treatment.

Conclusions

Respondents valued their independence as the most important factor in deciding whether to receive ongoing medical treatments in the intensive care unit. When clinicians are unable to obtain specific patient information, they should consider framing their decision making around the likelihood of the patient achieving functional independence rather than survival.

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Fig. 1

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available because they contain information that could compromise research participant privacy/consent.

References

  1. 1.

    Anstey MHR, Watts N, Orford N, Seppelt IM, Mitchell I. Does anyone ever expect to die? Anaesth Intensive Care. 2017;45:466–8.

    Article  Google Scholar 

  2. 2.

    Heyland DK, Barwich D, Pichora D, Dodek P, Lamontagne F, You JJ, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173:778–87.

    Article  Google Scholar 

  3. 3.

    Piers RD, Azoulay E, Ricou B, Dekeyser Ganz F, Decruyenaere J, Max A, et al. Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. J Am Med Assoc. 2011;306:2694–703.

    Article  CAS  Google Scholar 

  4. 4.

    Anstey MH, Adams JL, McGlynn EA. Perceptions of the appropriateness of care in California adult intensive care units. Crit Care. 2015;19:51.

    Article  Google Scholar 

  5. 5.

    Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med. 2000;28:3044–9.

    Article  CAS  Google Scholar 

  6. 6.

    Schubart JR, Toran L, Whitehead M, Levi BH, Green MJ. Informed decision making in advance care planning: concordance of patient self-reported diagnosis with physician diagnosis. Support Care Cancer. 2013;21:637–41.

    Article  Google Scholar 

  7. 7.

    Curtis JR, Patrick DL, Caldwell ES, Collier AC. Why don’t patients and physicians talk about end-of-life care? Barriers to communication for patients with acquired immunodeficiency syndrome and their primary care clinicians. Arch Intern Med. 2000;160:1690–6.

    Article  CAS  Google Scholar 

  8. 8.

    Hofmann JC, Wenger NS, Davis RB, Teno J, Connors AF, Desbiens N, et al. Patient preferences for communication with physicians about end-of-life decisions. SUPPORT Investigators. Study to understand prognoses and preference for outcomes and risks of treatment. Ann Intern Med. 1997;127:1–12.

    Article  CAS  Google Scholar 

  9. 9.

    Scheunemann LP, Cunningham TV, Arnold RM, Buddadhumaruk P, White DB. How clinicians discuss critically ill patients’ preferences and values with surrogates: an empirical analysis. Crit Care Med. 2015;43:757–64.

    Article  Google Scholar 

  10. 10.

    Scheunemann LP, Ernecoff NC, Buddadhumaruk P, Carson SS, Hough CL, Curtis JR, et al. Clinician-family communication about patients’ values and preferences in intensive care units. JAMA Intern Med. 2019;179:676–84.

    Article  Google Scholar 

  11. 11.

    Chiarchiaro J, Ernecoff NC, Scheunemann LP, Hough CL, Carson SS, Peterson MW, et al. Physicians rarely elicit critically ill patients’ previously expressed treatment preferences in intensive care units. Am J Respir Crit Care Med. 2017;196:242–5.

    Article  Google Scholar 

  12. 12.

    Scheunemann LP, Arnold RM, White DB. The facilitated values history. Am J Respir Crit Care Med. 2012;186:480–6.

    Article  Google Scholar 

  13. 13.

    You JJ, Downar J, Fowler RA, Lamontagne F, Ma IWY, Jayaraman D, et al. Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians. JAMA Intern Med. 2015;175:549–56.

    Article  Google Scholar 

  14. 14.

    de Bekker-Grob EW, Ryan M, Gerard K. Discrete choice experiments in health economics: a review of the literature. Health Econ. 2012;21:145–72.

    Article  Google Scholar 

  15. 15.

    Soekhai V, de Bekker-Grob EW, Ellis AR, Vass CM. Discrete choice experiments in health economics: past, present and future. Pharmacoeconomics. 2019;37:201–26.

    Article  Google Scholar 

  16. 16.

    Patrick DL, Starks HE, Cain KC, Uhlmann RF, Pearlman RA. Measuring preferences for health states worse than death. Med Decis Mak. 1994;14:9–18.

    Article  CAS  Google Scholar 

  17. 17.

    Rubin EB, Buehler AE, Halpern SD. States worse than death among hospitalized patients with serious illnesses. JAMA Intern Med. 2016;176:1557–9.

    Article  Google Scholar 

  18. 18.

    Kon AA, Shepard EK, Sederstrom NO, Swoboda SM, Marshall MF, Birriel B, et al. Defining futile and potentially inappropriate interventions: a policy statement from the Society of Critical Care Medicine Ethics Committee. Crit Care Med. 2016;44:1769–74.

    Article  Google Scholar 

  19. 19.

    Shah KK, Tsuchiya A, Wailoo AJ. Valuing health at the end of life: a stated preference discrete choice experiment. Soc Sci Med. 2015;124:48–56.

    Article  Google Scholar 

  20. 20.

    Mebane EW, Oman RF, Kroonen LT, Goldstein MK. The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making. J Am Geriatr Soc. 1999;47:579–91.

    Article  CAS  Google Scholar 

  21. 21.

    Gallo JJ, Straton JB, Klag MJ, Meoni LA, Sulmasy DP, Wang N, et al. Life-sustaining treatments: what do physicians want and do they express their wishes to others? J Am Geriatr Soc. 2003;51:961–9.

    Article  Google Scholar 

  22. 22.

    Marik PE, Varon J, Lisbon A, Reich HS. Physicians’ own preferences to the limitation and withdrawal of life-sustaining therapy. Resuscitation. 1999;42:197–201.

    Article  CAS  Google Scholar 

  23. 23.

    Uy J, White DB, Mohan D, Arnold RM, Barnato AE. Physicians’ decision-making roles for an acutely unstable critically and terminally ill patient. Crit Care Med. 2013;41:1511–7.

    Article  Google Scholar 

  24. 24.

    Dowdy DW, Eid MP, Sedrakyan A, Mendez-Tellez PA, Pronovost PJ, Herridge MS, et al. Quality of life in adult survivors of critical illness: a systematic review of the literature. Intensive Care Med. 2005;31:611–20.

    Article  Google Scholar 

  25. 25.

    Guentner K, Hoffman LA, Happ MB, Kim Y, Dabbs AD, Mendelsohn AB, et al. Preferences for mechanical ventilation among survivors of prolonged mechanical ventilation and tracheostomy. Am J Crit Care. 2006;15:65–77.

    Article  Google Scholar 

  26. 26.

    Mulhern B, Longworth L, Brazier J, Rowen D, Bansback N, Devlin N, et al. Binary choice health state valuation and mode of administration: head-to-head comparison of online and CAPI. Value Health J Int Soc Pharmacoeconomics Outcomes Res. 2013;16:104–13.

    Article  Google Scholar 

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Author information

Affiliations

Authors

Contributions

MHA initiated the project, co-developed the protocol and drafted the manuscript. RN led on data collection and analysis and assisted on drafting sections of the manuscript. IAM and CC co-developed the protocol, assisted with interpretation of findings, and provided comments and other input on the manuscript.

Corresponding author

Correspondence to Matthew H. Anstey.

Ethics declarations

Funding

This trial was supported by a Grant from the Sir Charles Gairdner Research Advisory Council (Grant no. 2016-17/023).

Conflict of interest

Matthew H. Anstey, Imogen A. Mitchell, Charlie Corke and Richard Norman have no conflicts of interest that are directly relevant to the content of this article.

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Anstey, M.H., Mitchell, I.A., Corke, C. et al. Population Preferences for Treatments When Critically Ill: A Discrete Choice Experiment. Patient 13, 339–346 (2020). https://doi.org/10.1007/s40271-020-00410-1

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