Intuitive vs Deliberative Approaches to Making Decisions About Life Support: A Randomized Clinical Trial

Abstract

Importance: Patients with serious illnesses are often encouraged to actively deliberate about the desirability of life support. Yet it is unknown whether deliberation changes the substance or quality of such decisions.

Objective: To identify differences in decisions about life support interventions and goals of care made intuitively vs deliberatively by patients with serious illnesses.

Design, setting, and participants: Randomized clinical trial in which patients were asked to express treatment preferences in a series of clinical scenarios. Participants were 199 hospitalized patients aged 60 years and older with serious oncologic, cardiac, and pulmonary illnesses treated in a large, urban academic hospital from July 1, 2015, through March 15, 2016.

Interventions: Patients in the intuitive group were subjected to a cognitive load and instructed to answer each question immediately based on gut instinct. Patients in the deliberative group were not cognitively loaded, were instructed to think carefully about their answers, and were required to explain their answers.

Main outcomes and measures: Choices regarding life support (4 scenarios) and goals of care (1 scenario), concordance of these choices with patients' valuations of health states that could follow from them, and decisional uncertainty.

Results: Of 199 patients, 132 (66%) were male and the mean (SD) age was 67.2 (5.0) years. Similar proportions of patients in the intuitive group (n = 97) and the deliberative group (n = 102) said they would accept a feeding tube for chronic aspiration (42% vs 44%, respectively; difference, -2%; 95% CI, -16% to 12%; P = .79), antibiotics for life-threatening infection in the event of terminal illness (39% vs 43%, respectively; difference, -4%; 95% CI, -18% to 10%; P = .57), a trial of mechanical ventilation (59% vs 60%, respectively; difference,-1%; 95% CI, -15% to 13%; P = .88), and a tracheostomy tube (37% vs 41%, respectively; difference, -4%; 95% CI, -22% to 13%; P = .64). Patients in the deliberative group were slightly more likely than patients in the intuitive group to choose a palliative approach to treatment in the event of serious illness (45% vs 30%, respectively; difference, 15%; 95% CI, 1%-29%; P = .04). Across scenarios, decisional uncertainty was similar between the 2 groups (all P > .05), and intuitive decisions were either equally or more closely aligned with patients' health state valuations than deliberative decisions.

Conclusions and relevance: In this study, encouraging hospitalized patients with serious illnesses to deliberate on end-of-life decisions did not change the content or improve the quality of these decisions. It is important to evaluate whether decision aids and structured communication interventions improve seriously ill patients' choices.

Trial registration: ClinicalTrials.gov Identifier: NCT02487810.

Figure 1.. CONSORT Flow Diagram of Recruitment, Enrollment, and Data Analysis

^aMissed patients were those who met eligibility criteria but were discharged from the hospital before they could be approached for consent.

Figure 2.. Acceptance of Specific Interventions and Preferred General Approach to Care Among Patients Making Decisions Intuitively and Deliberatively

A, In the intuitive group, n = 97 for all interventions except tracheostomy and n = 57 for tracheostomy (only patients who stated they would accept intubation were asked whether they would accept tracheostomy). In the deliberative group, n = 102 for all interventions except tracheostomy and n = 61 for tracheostomy. B, In the intuitive group, n = 87. In the deliberative group, n = 93. P values were calculated using χ² test.