Survey 1 Overview

In Round 1 of the modified Delphi process, all panel members were asked to brainstorm responses to 2 questions.  

The first question was whether there are additional criteria we should consider when deciding which interventions should be on the list. 

The second question asked which interventions (tests and procedures) might meet the criteria. 

Additionally, doctors and nurses on the panel were asked to review a list of commonly performed ICU procedures and indicate whether each intervention might meet all 3 criteria by selecting "Yes" or "No".   


Are there other criteria to consider? 

The question:

Are there other criteria that should be considered when deciding whether to include an intervention on this list besides the three below?

1. The intervention is potentially incompatible with one or more of the following common patient goals:

  • To be cured

  • To live longer

  • To improve health

  • To maintain health

  • To be comfortable

  • To accomplish a particular personal life goal (such as attending a birth or wedding)

2. The intervention has the potential to cause physical, emotional or financial harm to patients

3. The intervention can usually be anticipated on a non-emergent basis. 

Results:

9 people responded "Yes"

15 people responded "No"

If yes, what additional criteria should be considered?

"Not sure if this would be included in 'To maintain health' but an intervention that subsequently compromises the quality of life significantly might be considered as potentially inappropriate."

"Added to criterion #1: To maintain autonomy."

"Does the Caregiver know enough about the patient to be helpful?  Is the family a unity or do they have differing opinions.  The intervention may have to be started to find out."

"Under common patient goals maybe we should include something about not prolonging life?  The intervention would be incompatible with the wish to not prolong life, for example a tracheostomy or dialysis."

"The wishes of patient expressed in living will, advance directives, MOLST, or communications with POA"

"To be able to still interact with the environment and with others in a meaningful way.
To be able to survive outside a very highly monitored setting, like a hospital, for more than a month (or you can decide about an appropriate time period)."

"The intervention should be evidence based."

"Contact the patient's primary physician to receive their medical history when 1st admitted."

"1) Patient input. People often have experience of their own body that forms the basis of individual and specific knowledge. If patients are coherent enough to speak, considering their input even when it goes against standard protocol may be more beneficial than you'd expect, especially considering the growing prevalance of highly specific diseases, allergies, sensitivities, and autoimmune disorders. There is a growing population of people who have specific knowledge of their own bodies that doesn't necessarily fit standard textbook diagnoses. While there are still plenty of people who will come into a hospital setting and turn over all decisions to the experts who are treating them, this other population of people should be recognized and handled differently.
2) Mitigating stress. While ER and ICU treatment is typically a life-saving, front line situation in which it is appropriate to pull out all the stops in order to keep people alive, that is also an inherently very stressful situation - it's literally life and death, which triggers the sympathetic nervous system's fight-or-flight state. The body (I'm sure you know) has many self-regulating healing mechanisms and resources, but can't tap into them during sympathetic arousal. If it were possible to create calmer, more relaxing conditions which might allow the parasympathetic system's healing mechanisms to kick in, some patients would likely be able to respond to treatment better and heal better.
3) Slowing down. This follows #2 above. Slowing down to allow the body to rally it's resources and respond to treatment. In my case specifically, the aggressive treatment that was meant to save my life was also putting me in peril. I believe I would have done better if treatment were slower and less aggressive. I know I could have done at least a little better if staff could have listened to me about a couple of ideas that went against protocol which were based on my personal experience with my body. I do understand that they were saving my life and did not feel they could break protocol, so I don't fault them for it."


What interventions fit these criteria?

 The question: 

Are there diagnostic tests or procedures which you believe might meet the following three criteria?

1. The intervention is potentially incompatible with one or more of the following common patient goals:

  • To be cured

  • To live longer

  • To improve health

  • To maintain health

  • To be comfortable

  • To accomplish a particular personal life goal (such as attending a birth or wedding)

2. The intervention has the potential to cause physical, emotional or financial harm to patients

3. The intervention can usually be anticipated on a non-emergent basis. 

Results: 

12 people responded Yes

5 people responded No

7 people responded I don't know

If yes, please list those test or procedures here or describe situations where it might be important to ask about a patient's goals before proceeding.

"This is a very difficult question to answer as #1 covers so many goals but things like CRRT,ECMO,LVADs even chemo are all dependent on the patients individual situation. These procedures may be acceptable if the patient is having them to make it to see their daughter married but not if they have the false belief that they are curative (as cure is their goal)."

"Life support/decision to stop or continue  (patient unable to make that decision, up to family member)
Intubation of a conscious patient able to make their own decision
Dialysis
blood transfusions, antibiotics, extensive medications when Pt is terminal" 

"biopsies; imaging, with or without contrast; screening (for occult conditions); use of routine testing not specific to patient's medical condition, signs or symptoms; use of testing before other, less risky modalities (including watchful waiting or careful clinical evaluation by a specialist) have been employed first; tests to evaluate clinical matters not requiring immediate attention during the ICU stay; tests which will not change the management of the patient during the ICU stay; any test for which the balance between potential of benefit and potential of harm might be substantially shifted by a patient's personal preferences about risk"   

"Any invasive test such as lumbar puncture, thoracentesis/paracentesis, myelogram, bone marrow biopsy, endoscopy, etc.
Placement of invasive monitoring equipment such as PA catheters, ICP monitors, arterial catheters, etc.
Diagnostic surgical/interventional procedures such as biopsy, exploratory laparotomy, angiogram, etc."

"Daily ABG's & chest X-rays while on a ventilator can seem a bit redundant after many days in the ICU.  These interventions can hinder patients comfort and may not be necessary.  I feel as though these interventions should be more of a case to case decision."

"A tracheostomy, dialysis, invasive lines, MRI, bipap, intubation, even needle sticks for lab work if the patient's goal is comfort only."

"Surgical procedures, Mechanical ventilation (occassionally can be anticipated), Chemotherapy"

"Resuscitative therapies that can be instituted in the context of organ failure can be discussed proactively in these situations- ie, dialysis, mechanical ventilation, CPR."

"Resuscitation, ECMO placement, surgical interventions like sternotomy post surgery to revive circulation, intubation multiple , tracheostomy , enteral nutrition via PEG, CVVHD, blood transfusions, vaso-active agents to maintain BP in MOF"

"Any test related to cancer treatment.  Any surgery requiring amputation.  Any test with a risk of death."

"1) If too sick, not knowing what a patient's advanced directive is (i.e., pulling the plug). 2) When patient does not want a catheter in, it's placed anyway and patient was able to take it out anyway, without any intervention."

"1) consider including alternative/complimentary practitioners, perhaps as consultants. The body of knowledge of naturopaths, nutritionists, and homeopaths has grown exponentially and is much more supported by science than a few decades ago. Especially in situations where you have a non-textbook case, their additional perspective can be invaluable. Also, for those patients who are more inclined toward less intervention and avoiding chemicals, radiation, and other types of exposures, alternative/complimentary practitioners could be good advocates. Many of them are used to working hand-in-hand with standard medical practitioners on difficult issues such as cancer treatment and are able to tailor their recommendations to avoid conflicting with the treatments and goals of standard medicine. 
2) specifically, homeopathic remedies often work quickly and usually do not have adverse interactions with other medicines. They also do not cause side effects. While there may be leass scientific research on them than would be ideal, because they also do not cause harmful side effects or dangerous interactions, they don't cause any harm, so for those cases in which standard treatments are not working or standard diagnosis isn't fitting, there doesn't seem to be any reason not to try them.
3) Nutrition is the basis of health. While nutrition often takes time to show results when it's used to heal a condition and so is probably not appropriate as a front-line treatment, it is also key that we provide the body with the nutritional building blocks it needs in order to be able to heal. "


ICU Interventions

The 12 doctors and nurses on the panel were shown a long list of interventions commonly performed in the ICU and instructed:

"Please indicate whether each intervention below might meet all three criteria above by selecting yes or no."

12 (100%) of doctors and nurses selected "yes" for the following interventions:

Dialysis catheter (permanent), Suprapubic catheter, Feeding tube (gastric, oral, nasal), Peritoneal dialysis

 

11 (92%) of doctors and nurses selected "yes" for the following interventions:

Tracheotomy, Coronary angioplasty, Pericardiocentesis, Esophagogastroduodenoscopy (EGD), Colonoscopy,  Cardiac Angiography,  Angiography (other than cardiac)

 

10 (83%) of doctors and nurses selected "yes" for the following interventions:

Extracorporeal life support (ECLS), Bronchoscopy (rigid or fiberoptic), Cardiac pacemaker (Permanent), Subcutaneous venous port (e.g., portacath), Echocardiography - Transoesophageal, Dialysis catheter (temporary), Percutaneous gall bladder drain, Intraabdominal drain placement, Paracentesis, Lumbar puncture, Epidural catheter, Nasogastric Tube

 

9 (75%) of doctors and nurses selected "yes" for the following interventions:

Endotrachael intubation,  Mechanical ventilation via endotracheal tube or tracheostomy,  Thoracocentesis, Chest tube, Defibrillation, Central venous catheter (temporary), Tunneled central venous catheter (e.g., Hickman catheter), Arthrocentesis, cricothyrotomy, Sengstaken-Blakemore or Minnesota tube, Renal replacement therapy or Continuous veno-venous hemofiltration (CVVH), Prone positioning during mechanical ventilation, PET scan, Nuclear medicine scan (i.e. VQ), Arterial Line (radial), Arterial Line (femoral)

 

8 (67%) of doctors and nurses selected "yes" for the following interventions:

Non-invasive ventilation/CPAP/BiPAP, Cardioversion, Pulmonary artery catheter, intraaortic balloon pump, foley catheter, subdural “bolt” for intracranial pressure measurement, Intraventricular monitor / drain for ICP measurement / treatment, Jugular bulb oximetry, MRI 

 

7 (58%) of doctors and nurses selected "yes" for the following interventions:

Cardiac pacemaker (temporary), Percutaneously inserted central catheter (PICC line), CT scan, Intraosseous vascular access

 

6 (50%) of doctors and nurses selected "yes" for the following interventions:

Rectal tube / fecal management system, X-ray, Peripheral intravenous line (IV), Skin suturing

5 (42%) of doctors and nurses selected "yes" for the following interventions:

Echocardiography- Transthoracic,  Eletroencephalography (EEG)

4 (33%) of doctors and nurses selected "yes" for the following interventions:

Isolation