Projects

WikiDecision: Implementation and evaluation of a context-adapted wiki-based DA and training program supporting critically ill patients’ decisions about life-sustaining therapies

BACKGROUND

The number of elderly patients being admitted to the hospital for the last days of their life is increasing in Canada and many receive unwarranted life-sustaining therapies, such as cardiopulmonary resuscitation (CPR) and mechanical ventilation, in part due to clinicians’ failures to elicit patients’ values and goals of care. Practice guidelines recommend that shared decision making (SDM) should be used to engage patients and their families in discussions about care that is congruent with their values. Clinician training and the implementation of decision aids (DAs) can enhance the adoption of SDM. Previously, we created a context-adapted wiki-based DA for discussing goals of care, including CPR and mechanical ventilation, that can be adapted to other settings. This DA is available at www.wikidecision.org. We are currently developing a multifaceted intervention including a training program to teach clinicians how to use SDM and our DA.

OBJECTIVES

This project aims to improve care for elderly patients by implementing and evaluating a clinician training program and a context-adapted wiki-based DA for discussing goals of care, CPR and mechanical ventilation with elderly patients admitted to the intensive care unit (ICU) of one hospital in Quebec. Our specific objectives are to evaluate the:

1. Feasibility of implementing our multifaceted intervention;
2. Feasibility of measuring the effect of our intervention on patient-level outcomes and clinician-level outcomes;Training intervention: We will train all ICU physicians to use SDM and to use our wiki-based DA when discussing goals of care with elderly patients and families. The training will consist of a sixty-minute online professional development module and a sixty-minute in-person training session. We will evaluate participant’s satisfaction with a 7-item post-test questionnaire and measure the impact of our training program on clinicians’ intention to adopt SDM for discussing goals of care with their patients using a validated theory-based questionnaire. After training the physicians in using our wiki-based decision aid, we will video- and audio-record 10 new dyads of elderly patient and physician dyads discussing goals of care. We will again use the OPTION-12 scale to measure SDM adoption and a fidelity checklist based on the CARENET Quality Indicators for Goals of Care Communication and Decision Making to evaluate the quality of decision making. We will again collect patient-level qualitative outcomes and document their decisions about their goals of care.
3. Expected outcomes: This study will inform the feasibility of studying the impact of implementing a DA and SDM training program on the level of adoption of SDM (measured by the OPTION 12 scale) and the quality of goals of care decision making (using CARENET Quality Indicators for Goals of Care Communication and Decision Making). This project will also inform future studies trying to determine the impact of SDM on the quality of decision making and congruence of decisions with patients values and preferences.
4. Methods: This will be a prospective three phase implementation study conducted in one ICU in the Centre intégré en santé et en services sociaux de Chaudière-Appalaches (CISSS CA). Phase 1 – Pre-test evaluation: We will video and audio record 10 dyads of elderly patient and physician dyads discussing goals of care in each ICU. Two reviewers will use the OPTION- 12 scale to measure SDM adoption and a fidelity checklist based on the CARENET Quality Indicators for Goals of Care Communication and Decision Making to evaluate the quality of decision making. We will also collect patient-level qualitative outcomes (decision making process outcomes (e.g., qualitative data about patient misunderstandings about goals of care discussions, patients’ questions about the goals of care discussions) and document their decisions about their goals of care. Phase 2 – Implementation of our wiki-based decision aid: After making our wiki-based decision aid available to the 4 clinicians in the participating unit, we will video- and audio-record 10 new dyads of elderly patient and physician dyads discussing goals of care. We will again use the OPTION-12 scale to measure SDM adoption and a fidelity checklist based on the CARENET Quality Indicators for Goals of Care Communication and Decision Making to evaluate the quality of decision making. We will collect patient-level qualitative outcomes and document their decisions about their goals of care.