Survey 2 Overview

In Round 2 of the modified Delphi process, all panel members were shown three possible patient goals suggested in Round 1 and asked to vote on whether they should be added to the list of common patient goals.  These 3 suggested patient goals were: 

  1. Maintain autonomy

  2. Continue to interact with others in a meaningful way

  3. Not prolong life

Former ICU patients and patient-surrogates on the panel reviewed 13 trade-offs associated with ICU interventions and ranked them by how important they are to explain to an ICU patient or their family. 

ICU doctors and nurses on the panel reviewed a list of 43 ICU interventions and rated each on the following 3 statements using a 1 - 9 Likert scale with 1 = Strongly Disagree and 9 = Strongly Agree.

  1. This intervention is potentially incompatible with one or more common patient goals

  2. This intervention is potentially physically, emotionally, or financially harmful

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


Other Criteria?

In Round 2 of the modified Delphi process, all panel members were shown three possible patient goals suggested in Round 1 and asked to vote on whether they should be added to the list of common patient goals.  The results are below: 

Continue to interact with others in a meaningful way - 92% approval

22 out of 24 people voted YES.

Maintain autonomy - 88% approval

21 out of 24 people voted YES.

Not prolong life - 67% approval

16 out of 24 people voted YES.


Trade-offs

11 former ICU patients and patient-surrogates on the panel reviewed 13 trade-offs associated with ICU interventions and ranked them by how important they are to explain to an ICU patient or their family. 

For each trade-off we calculated the median rank.  For example, the trade-off: "The patient will require care in a residential facility (nursing home) for the rest of their lives" received the following ranks: 

1, 2, 2, 3, 3, 4, 5, 5, 6, 6, 11

The median rank is the number in the middle of the list - 4.  At least 50% of ICU patients and patient-surrogates on the panel ranked this trade-off 4th or higher. 

The results for all trade-offs are below. 

1st place tie:  Median rank = 3

  •  The procedure could permanently effect the patient's ability to think clearly or remember people's names

  • The patient might not be able to chew, swallow, or put food in their mouth for the rest of their life

3rd place tie:  Median rank = 4

  • The patient will require care in a residential facility (nursing home) for the rest of their lives

  • The procedure might permanently limit a patient's ability to talk or communicate

5th place:  Median rank = 5

  • The procedure or test is very expensive and may not be covered by insurance

6th place tie:  Median rank = 6

  • The patient might not be able to use the bathroom alone for the rest of life (may need diapers)

  • The procedure will need to be "stopped" or "turned off" before the patient can die naturally (i.e. A decision to stop treatment will need to be made)

8th place:  Median rank = 7

  • The procedure or test is very painful

9th place:  Median rank = 8

  • The procedure will require the patient to visit a treatment center multiple times per week for rest of life

10th place:  Median rank = 9

  • The patient will need to be connect to a machine at home each night for the rest of life

11th place:  Median rank = 10

  • The patient will look very different after the procedure (for example a large scar in a clearly visible place)

12th place:  Median rank = 11

  • The patient must be sedated or asleep for days during treatment

  • The patient will require weekly or monthly blood tests for the rest of life. 


Potential Interventions

12 ICU doctors and nurses on the panel were asked to think about 43 interventions performed in ICUs.  Each doctor or nurse was asked to think about 3 statements for each intervention: 

  1. The intervention is potentially incompatible with one or more common patient goals

  2. The intervention is potentially physically, emotionally, or financially harmful

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

In response to each statement, the intervention was ranked on a 1-9 Likert scale with 1 = Strongly Disagree and 9 - Strongly Agree.  For each combination intervention and statement we calculated the median rank. For example, the intervention "endotrachael intubation" received the following ranks on each of the 3 statements: 

1. The intervention is potentially incompatible with one or more common patient goals

1, 4, 6, 6, 7, 7, 7, 8, 9, 9, 9,  (one person didn't vote)

 

2. The intervention is potentially physically, emotionally, or financially harmful

6, 7, 7, 7, 7, 8, 8, 8, 9, 9, 9, 9

 

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

1, 1, 1, 2, 2, 3, 3, 3, 3, 3, 4, 6

 

The median rank is the number in the middle of each list.  So the median rank for the 1st criteria is 7, the median rank for the 2nd criteria is 8, and the median rank for the 3rd criteria is 3.  This means the majority of doctors and nurses thought that endotrachael intubation was potentially incompatible with at least one common patient goal, and potentially harmful, but not easy to anticipate.

The total rank for endotracheal intubation is the sum of it's median ranks on the 3 criteria: 7+8+3=18.  The total score for each intervention is below.  

Total score = 20

Renal replacement therapy or Continuous venovenous hemofiltration  (CVVH);  Nasogastric Tube

Total score = 19.5 or 19

Tracheotomy; Subcutaneous venous port portacath;  Rectal tube fecal management system; 

Total score = 18.5 or 18

Endoscopy- upper or lower;  Extracorporeal life support (ECLS);  Endotrachael intubation;  Lumbar puncture

Total score  = 17.5 or 17

Mechanical ventilation via endotracheal tube or tracheostomy;  Intraaortic balloon pump;  Chest tube; Pulmonary artery catheter;  Epidural catheter; Bronchoscopy  rigid or fiberoptic;  Paracentesis;  Echocardiography Transthoracic;  Arthrocentesis; PET scan 

Total score = 16.5 or 16

Prone positioning during mechanical ventilation; Abdominal drain - gallbladder or other;  Sengstaken Blakemore or Minnesota tube; ICP montoring (subdural or intravenicular); Intraosseous or intravenous (IO or IV) access; Thoracocentesis; Nuclear medicine scan  (i.e. VQ);  Foley catheter; 

Total score = 15.5 or 15

Jugular bulb oximetry; Defibrillation cardioversion; Invasive cardiac procedures including pericardiocentesis and angiography; Arterial line - radial or femoral

Total score = 14.5 or 14

Noninvasive ventilation CPAP BiPAP;  PICC line; Isolation

Total score < 14

Central Venous Access Tunneled or Non; MRI; Cardiac pacemaker temporary; CT scan; X-ray;  Electroencephalography  (EEG);  Skin suturing