Assignment: Vasoactive Drips

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Assignment: Vasoactive Drips

Assignment: Vasoactive Drips

Clinicians and patients/surrogates should use a shared decision-making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences (7, 8). Once clinicians and the patient/surrogate agree on general goals of care, clinicians confront many routine decisions (e.g., choice of vasoactive drips and rates, laboratory testing, fluid rate). It is

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logistically impractical to involve patients/surrogates in each of these decisions. Partnerships in decision-making require that the overall goals of care and major preference-sensitive decisions be made using a shared decision-making approach. The clinician then has a fiduciary responsibility to use experience and evidence-based practice when making day-to-day treatment decisions that are consistent with the patient’s values, goals, and preferences. Throughout the ICU stay, important, preference-sensitive choices often arise. When they do, clinicians should employ shared decision-making.

Clinicians should generally start with a default shared decision- making approach that includes the following three main elements: information exchange, deliberation, and making a treatment decision. This model should be considered the default approach to shared decision-making, and should be modified according to the needs and preferences of the patient/surrogate. Using such a model, the patient or surrogate shares information about the patient’s values, goals, and preferences that are relevant to the decision at hand. Clinicians share information about the relevant treatment options and their risks and benefits, including the option of palliative care without life-prolonging interventions. Clinicians and the patient/surrogate then deliberate together to determine which option is most appropriate for the patient, and together they agree on a care plan. In such a model, the authority and burden of decision-making is shared relatively equally (9). Although data suggest that a preponderance of patients/surrogates prefer to share responsibility for decision-making relatively equally with clinicians, many patients/surrogates prefer to exercise greater authority in decision-making, and many other patients/surrogates prefer to defer even highly value-laden choices to clinicians (10–13). Ethically justifiable models of decision-making include a broad range to accommodate such differences in needs and preferences.

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