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J Pain Symptom Manage. 2018 Nov 5. pii: S0885-3924(18)31060-1. doi: 10.1016/j.jpainsymman.2018.10.513. [Epub ahead of print]

Development and Pilot Testing of a Simulation to Study How Physicians Facilitate Surrogate Decision-Making Based on Critically Ill Patients' Values and Preferences.

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Division of Geriatric Medicine and Gerontology, University of Pittsburgh, Pittsburgh, PA, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA. Electronic address:
St. Clair Hospital, Pittsburgh, PA, USA.
Division of Hematology/Oncology, University of Chicago, IL, USA.
Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA; Palliative and Supportive Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.



There are no evidence-based programs to train physicians to facilitate shared decision-making based on incapacitated intensive care unit (ICU) patients' values and preferences.


To develop a high-fidelity simulation to fill this gap.


Case development involved 6 steps: 1) drafting a case about an elderly patient receiving prolonged mechanical ventilation; 2) engaging an expert advisory board to optimize case content; 3) revising the case based on advisory board input; 4) training actors to portray the case patient's daughter; 5) obtaining physician feedback on the simulation; 6) revising the case based on their feedback. We conducted a cross-sectional pilot study with 50 physicians to assess feasibility and acceptability, defined a priori as an enrollment rate > 40 physicians/year, study procedures <75 minutes/participant, >95% actor adherence to standardization rules, and high physician ratings of realism and acceptability.


Advisory panel feedback yielded two modifications: 1) refocusing the case on decision-making about tracheostomy and percutaneous gastrostomy; 2) making the patient's values more authentic. Physician feedback yielded two additional modifications: 1) reducing how readily the actor divulged the patient's values; 2) making her more emotional. All 50 physicians enrolled in the pilot study over 11 months completed study procedures in <75 minutes. Actor adherence to standardization rules was 95.8%. Physicians' mean ratings of realism and acceptability were 8.4 and 9.1 respectively on a 10-point scale.


Simulation is feasible, acceptable, and can be adequately standardized to study physicians' skills for facilitating surrogate decision-making based on an incapacitated ICU patient's values and preferences.


ICU family communication; Shared decision-making; patient values and preferences; surrogate decision-making

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