Selecting and evaluating decision-making strategies in the intensive care unit: A systematic review

Purpose: Many patients in the Intensive Care Unit (ICU) die after a decision to withhold or withdraw treatment. To ensure that for each patient the appropriate decision is taken, a careful decision-making process is required. This review identifies strategies that can be used to optimize the decision-making process for continuing versus limiting life sustaining treatment of ICU patients. Methods: We conducted a systematic review of the literature by searching PUBMED and EMBASE. Results: Thirty-two studies were included, with five categories of decision-making strategies (1) integrated communication, (2) consultative communication, (3) ethics consultation, (4) palliative care consultation and (5) decision aids. Many different outcome measures were used and none of them covered all aspects of decisions on continuing versus limiting life sustaining treatment. Integrated communication strategies had a positive effect on multiple outcome measures. Frequent, predefined family-meetings as well as triggered and integrated ethical or palliative consultation were able to reduce length of stay of patients who eventually died, without increasing overall mortality. Conclusions: The decision-making process in the ICU can be enhanced by frequent family-meetings with predefined topics. Ethical and palliative support is useful in specific situations. These interventions can reduce non-beneficial ICU treatment days. (C) 2019 Elsevier Inc. All rights reserved.