Personalizing Patients' Advance Directives Decreases the Willingness of Intensive Care Unit Residents to Stop Treatment: A Randomized Study

摘要

Background: While following patients' advance directives (ADs) is legally binding, French physicians in Intensive Care Unit (ICU) perceive them as complicating their decision. Decision making and ICU residents benefit from personalizing the dying process. In France, ADs can include personal information. Objective: Whether personalizing ADs affects ICU residents' decisions and perception of the patient. Subjects and Design: Sixty-six ICU residents assigned to three experimental groups and presented with a case file for an ICU patient. The files were identical except for the patient's AD, which was manipulated to give three conditions: No Personal Information, Sociodemographic Information, and Agency Information (ability to plan and act upon the world). Measurements: Residents evaluated the relevance of the AD, assessed its influence on medical decisions, and decided whether to stop treatment, postpone the decision, or consult the family. Finally, they evaluated the patient with respect to two dimensions of personhood (agency and experience). Results: Residents in all conditions considered the AD to be highly relevant and influential. Residents in both Information conditions perceived the patient as having more capacities for agency and for experience than those in the No Information condition. They were also less likely to stop treatment and more likely to postpone their decision. Consulting the family was not sensitive to the information condition. Conclusion: Personalizing ADs of an unknown patient leads ICU residents to be less prone to follow them, but does not affect whether or not they decide to consult the patient's family. Hence, promoting shared decision making by including the incapacitated patients' families in treatment decisions is a major challenge, especially in countries such as France, where ADs are legally binding.