Physicians' mental models regarding appropriate goals of care in chronic critical illness: a qualitative interview study.

Abstract

There is a need to improve shared decision making about goals of care (GOC) for patients with chronic critical illness (CCI). Understanding the mental models that inform how physicians approach GOC decisions in CCI is necessary to improve shared decision making. What factors prompt physicians to revisit existing GOC decisions for patients with CCI and influence their judgments of appropriate GOC in CCI? How do external health system factors, including access to long-term ventilator facilities, influence physicians' mental models about GOC in CCI? AND METHODS: We conducted semi-structured interviews with a purposive sample of intensivists in the United States and Canada. We used a mental models approach from the field of decision science to identify the factors that these intensivists described as influencing their judgments of appropriate goals of care in CCI and when to revisit goals of care. We interviewed 29 physicians from six institutions with varying access to long-term ventilator facilities. The primary factors that physicians described as influencing their personal judgments about GOC in CCI and their decisions to initiate new GOC discussions were an illness trajectory that remained flat over days to weeks, especially with limited apparent potential for a good functional outcome and acceptable quality of life. Increased access to long-term ventilator facilities was perceived to delay or defer GOC decisions. Other external influences included institutional norms and priorities regarding high-intensity treatments, patient turnover, and use of palliative care. In this qualitative interview study, physicians described predictions about future quality of life and functional outcome as central to initiating and resolving decisions about goals of care in CCI. Greater awareness of functional and quality of life outcomes in CCI, as well as how health system factors influence physician mental models may improve GOC decision-making in chronic critical illness.