Shared Decision-Making for Patients with Stroke in Neurocritical Care: A Qualitative Meta-Synthesis

Abstract

Decision-making for patients with stroke in neurocritical care is uniquely challenging because of the gravity and high preference sensitivity of these decisions. Shared decision-making (SDM) is recommended to align decisions with patient values. However, limited evidence exists on the experiences and perceptions of key stakeholders involved in SDM for neurocritical patients with stroke. This review aims to address this gap by providing a comprehensive analysis of the experiences and perspectives of those involved in SDM for neurocritical stroke care to inform best practices in this context. A qualitative meta-synthesis was conducted following the methodological guidelines of the Joanna Briggs Institute (JBI), using the thematic synthesis approach outlined by Thomas and Harden. Database searches covered PubMed, CIHAHL, EMBASE, PsycINFO, and Web of Science from inception to July 2023, supplemented by manual searches. After screening, quality appraisal was performed using the JBI Appraisal Checklist. Data analysis comprised line-by-line coding, development of descriptive themes, and creation of analytical themes using NVivo 12 software. The initial search yielded 7,492 articles, with 94 undergoing full-text screening. Eighteen articles from five countries, published between 2010 and 2023, were included in the meta-synthesis. These studies focused on the SDM process, covering life-sustaining treatments (LSTs), palliative care, and end-of-life care, with LST decisions being most common. Four analytical themes, encompassing ten descriptive themes, emerged: prognostic uncertainty, multifaceted balancing act, tripartite role dynamics and information exchange, and influences of sociocultural context. These themes form the basis for a conceptual model offering deeper insights into the essential elements, relationships, and behaviors that characterize SDM in neurocritical care. This meta-synthesis of 18 primary studies offers a higher-order interpretation and an emerging conceptual understanding of SDM in neurocritical care, with implications for practice and further research. The complex role dynamics among SDM stakeholders require careful consideration, highlighting the need for stroke-specific communication strategies. Expanding the evidence base across diverse sociocultural settings is critical to enhance the understanding of SDM in neurocritical patients with stroke.Trial registration This study is registered with PROSPERO under the registration number CRD42023461608.

Keywords: Critical care; Qualitative research; Shared decision-making; Stroke.

Fig. 1

This flowchart represents the process of literature inclusion following the standard PRISMA format. It provides a clear overview of the data sources and the literature screening steps. A total of 94 articles were screened in full text, with 76 being excluded for not meeting the inclusion criteria. This left 18 articles that were ultimately included in the final meta-synthesis. The flowchart also details the specific reasons for excluding articles during the full-text assessment stage. PRISMA Preferred Reporting Items for Systematic reviews and Meta-Analyses, SDM shared decision-making

Fig. 2

This conceptual model diagram illustrates the complex dynamics of SDM in neurocritical stroke care. At its base is prognostic uncertainty, which acts as the fulcrum around which other SDM elements revolve. Above this foundation, the three key parties involved in SDM (patient, family, and HSCPs) operate within a broader sociocultural context. Prognostic uncertainty serves as the fulcrum for the balance board, and the difficulty of finding equilibrium depends on the level of uncertainty. As time progresses and prognostic uncertainty decreases, the complexity of this balancing process tends to ease. The model also underscores the complex role dynamics and information exchange among the three SDM parties. The thicker line in the diagram indicates that family members and HSCPs typically have more frequent direct interactions, whereas patients may engage less directly. However, the preferences of patients, whether explicitly stated or inferred, remain central to the decision-making process. These interactions are significantly influenced by the sociocultural context, which impacts the experiences of decision-makers, ultimately affecting the outcomes of SDM. HSCPs health and social care professionals, SDM shared decision-making