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CMAJ. 2019 Jun 17;191(24):E652-E663. doi: 10.1503/cmaj.190154.

Factors influencing decisions by critical care physicians to withdraw life-sustaining treatments in critically ill adult patients with severe traumatic brain injury.

Author information

1
CHU de Québec - Université Laval Research Centre (Turgeon, Archambault, Lauzier, Moore, Boutin), Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, and Division of Critical Care Medicine (Turgeon, Archambault, Lauzier), Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, Que.; Clinical Epidemiology Program (Dorrance, English, McIntyre, Squires), Ottawa Hospital Research Institute, Ottawa, Ont.; Departments of Family and Emergency Medicine (Archambault), and Medicine (Lauzier), Faculty of Medicine, Université Laval, Québec, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke; Centre de recherche du CHU de Sherbrooke (Lamontagne), Sherbrooke, Que.; Department of Internal Medicine (Zarychanski), Sections of Critical Care Medicine, Haematology and Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, Man.; Sunnybrook Research Institute (Fowler, Scales), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Social and Preventive Medicine (Moore), Université Laval, Québec, Que.; CHU Ste-Justine Research Centre (Lacroix), CHU Ste-Justine and Department of Medicine (Bernard), Université de Montréal, Montréal, Que.; Division of Critical Care (English, McIntyre), Department of Medicine, University of Ottawa, Ottawa, Ont.; Department of Critical Care Medicine (Muscedere) and Kingston Health Sciences Centre, Queen's University, Kingston, Ont.; Interdepartmental Division of Critical Care Medicine (Burns), University of Toronto; Li Ka Shing Knowledge Institute (Burns), St. Michael's Hospital, Toronto, Ont.; Division of Critical Care Medicine (Griesdale), Department of Medicine, and Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Department of Medicine (Bernard), Université de Montréal, Montréal, Que.; Daphne Cockwell School of Nursing (Yamada), Ryerson University, Toronto, Ont.; School of Nursing (Squires), University of Ottawa, Ottawa, Ont. alexis.turgeon@fmed.ulaval.ca.
2
CHU de Québec - Université Laval Research Centre (Turgeon, Archambault, Lauzier, Moore, Boutin), Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, and Division of Critical Care Medicine (Turgeon, Archambault, Lauzier), Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, Que.; Clinical Epidemiology Program (Dorrance, English, McIntyre, Squires), Ottawa Hospital Research Institute, Ottawa, Ont.; Departments of Family and Emergency Medicine (Archambault), and Medicine (Lauzier), Faculty of Medicine, Université Laval, Québec, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke; Centre de recherche du CHU de Sherbrooke (Lamontagne), Sherbrooke, Que.; Department of Internal Medicine (Zarychanski), Sections of Critical Care Medicine, Haematology and Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, Man.; Sunnybrook Research Institute (Fowler, Scales), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Social and Preventive Medicine (Moore), Université Laval, Québec, Que.; CHU Ste-Justine Research Centre (Lacroix), CHU Ste-Justine and Department of Medicine (Bernard), Université de Montréal, Montréal, Que.; Division of Critical Care (English, McIntyre), Department of Medicine, University of Ottawa, Ottawa, Ont.; Department of Critical Care Medicine (Muscedere) and Kingston Health Sciences Centre, Queen's University, Kingston, Ont.; Interdepartmental Division of Critical Care Medicine (Burns), University of Toronto; Li Ka Shing Knowledge Institute (Burns), St. Michael's Hospital, Toronto, Ont.; Division of Critical Care Medicine (Griesdale), Department of Medicine, and Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Department of Medicine (Bernard), Université de Montréal, Montréal, Que.; Daphne Cockwell School of Nursing (Yamada), Ryerson University, Toronto, Ont.; School of Nursing (Squires), University of Ottawa, Ottawa, Ont.

Abstract

BACKGROUND:

Most deaths in critically ill patients with severe traumatic brain injury are associated with a decision to withdraw life-sustaining treatments. We aimed to identify the behavioural determinants that influence recommendations by critical care physicians to consider the withdrawal of life-sustaining treatments in this population.

METHODS:

We conducted a descriptive qualitative study based on the Theoretical Domains Framework of critical care physicians caring for patients with severe traumatic brain injury across Canada. We stratified critical care physicians by regions and used a purposive sampling strategy. We conducted semistructured phone interviews using a piloted and pretested interview guide. We transcribed the interviews verbatim and verified the content for accuracy. We performed the analysis using a 3-step approach: coding, generation of specific beliefs and generation of specific themes.

RESULTS:

We recruited 20 critical care physicians across 4 geographic regions. After reaching saturation, we identified 7 core themes across 4 Theoretical Domains Framework domains for factors relevant to the decision to withdraw life-sustaining treatments. Four factors (i.e., clinical triggers, social triggers, interaction with families and intentions with medical decisions) were identified before the decision is made and 3 were identified during the decision-making process (i.e., considerations, priorities and knowledge needs). We identified multiple themes reflecting internal (n = 18, 8 Theoretical Domains Framework domains) and external (n = 15, 6 Theoretical Domains Framework domains) influences on the decision to withdraw life-sustaining treatments.

INTERPRETATION:

We identified several core themes and domains considered by critical care physicians in Canada in the decision to withdraw life-sustaining treatments in critically ill patients with severe traumatic brain injury. Future research should aim at identifying the factors influencing surrogate decision-makers in the decision to withdraw life-sustaining treatments in these patients.

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