Assignment: The Discretion of Surrogates
Shared Decision-Making in Intensive Care Units Executive Summary of the American College of Critical Care Medicine and American Thoracic Society Policy Statement
Shared decision-making is a central component of patient-centered care in the intensive care unit (ICU) (1–4); however, there remains confusion about what shared decision-making is and when shared decision-making ought to be used. Further, failure to employ appropriate decision-making techniques can lead to significant problems. For example, if clinicians leave decisions largely to the discretion of surrogates without providing adequate support, surrogates may struggle to make patient-centered decisions and may experience psychological distress (5). Conversely, if clinicians make treatment decisions without attempting to understand the patient’s values, goals, and preferences, decisions will likely be predominantly based on the clinicians’ values, rather than the patient’s, and patients or surrogates may feel they have been unfairly excluded from decision-making (1, 2). Finding the right balance is therefore essential. To clarify these issues and provide guidance, the American College of Critical Care Medicine (ACCM) and American Thoracic Society (ATS) recently released a policy statement that provides a definition of shared decision-making in the ICU environment, clarification regarding the range of appropriate models for decision-making in the ICU, a set of skills to help clinicians create genuine partnerships in decision-making with patients/surrogates, and ethical analysis supporting the findings (6).
To develop a unified policy statement, the Ethics Committee of the ACCM and the Ethics and Conflict of Interest Committee of the ATS convened a writing group composed of members of these committees. The writing group reviewed pertinent literature published in a broad array of journals, including those with a focus in medicine, surgery, critical care, pediatrics, and bioethics, and discussed findings with the full ACCM and ATS ethics committees throughout the writing process. Recommendations were generated after review of empirical research and normative analyses published in peer-reviewed journals. The policy statement was reviewed, edited, and approved by consensus of the full Ethics Committee of the ACCM and the full Ethics and Conflict of Interest Committee of the ATS. The statement was subsequently reviewed and approved by the ATS, ACCM, and Society of Critical Care Medicine leadership, through the organizations’ standard review and approval processes.
ACCM and ATS endorse the following definition: Shared decision-making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals, and preferences.
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