Assignment: Conditions and Prognosis
Under such a model, the surrogate cedes decision-making authority to the clinician and does not need to explicitly agree to (and thereby take responsibility for) the decision that is made. The clinician should explain not only what decision the clinician is making but also the rationale for the decision, and must then explicitly give the surrogate the opportunity to disagree. If the surrogate does not disagree, it is reasonable to implement the care decision (19–24). Readers may review references 19–24 for detailed descriptions and ethical analyses of clinician-directed decision-making.
The statement was intended for use in all ICU environments. Patients and surrogate decision-makers have similar rights both to participate in decision-making when appropriate and to rely more heavily on providers when they wish to do so, regardless of the type of ICU. Similarly, the statement is equally applicable in pediatric and neonatal settings, where decision-making partnerships between parents and the ICU team are equally important. As noted in the statement, including children in some decisions can often be appropriate as well. The statement is also intended to be applicable internationally. Although patient and surrogate decision-making preferences may differ globally, the default approach presented and the recommendation to adjust the decision-making model to fit the preferences of the patient or surrogate are universal. Both ACCM and ATS are international organizations, and the literature review included publications from many countries. The statement focuses on the ICU environment because critically ill patients are often, but not always, unable to participate in decision-making themselves, and because many decisions in the ICU are value- sensitive. The recommendations in the statement, however, could be equally applicable in all patient care settings.
To optimize shared decision-making, clinicians should be trained in specific communication skills. Core categories of skills include establishing a trusting relationship with the patient/surrogate; providing emotional support; assessing patients’/surrogates’ understanding of the situation; explaining the patient’s condition and prognosis; highlighting that there are options to choose from; explaining principles of surrogate decision-making; explaining treatment options; eliciting patient’s values, goals, and preferences; deliberating together; and making a decision. The full policy statement provides significant guidance and examples in these areas (6).
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