title: Communication tools for end-of-life decision-making in the intensive care unit: a systematic review and meta-analysis.
abstract: BACKGROUND
  For many patients admitted to the intensive care unit (ICU), preferences for end-of-life care are unknown, and clinicians and substitute decision-makers are required to make decisions about the goals of care on their behalf. We conducted a systematic review to determine the effect of structured communication tools for end-of-life decision-making, compared to usual care, upon the number of documented goals of care discussions, documented code status, and decisions to withdraw life-sustaining treatments, in adult patients admitted to the ICU.
  
  
  METHODS
  We searched multiple databases including MEDLINE, Embase, CINAHL, ERIC, and Cochrane from database inception until July 2014. Two reviewers independently screened articles, assessed eligibility, verified data extraction, and assessed risk of bias using the tool described by the Cochrane Collaboration and the Newcastle Ottawa Scale. Pooled estimates of effect (relative risk, standardized mean difference, or mean difference), were calculated where sufficient data existed. GRADE was used to evaluate the overall quality of evidence for each outcome.
  
  
  RESULTS
  We screened 5785 abstracts and reviewed the full text of 424 articles, finding 168 eligible articles, including 19 studies in the ICU setting. The use of communication tools increased documentation of goals-of-care discussions (RR 3.47, 95% CI 1.55, 7.75, p = 0.020, very low-quality evidence), but did not have an effect on code status documentation (RR 1.03, 95% CI 0.96, 1.10, p = 0.540, low-quality evidence) or decisions to withdraw or withhold life-sustaining treatments (RR 0.98, 95% CI 0.89, 1.08, p = 0.70, low-quality evidence). The use of such tools was associated with a decrease in multiple measures of health care resource utilization, including duration of mechanical ventilation (MD -1.9 days, 95% CI -3.26, -0.54, p = 0.006, very low-quality evidence), length of ICU stay (MD -1.11 days, 95% CI -2.18, -0.03, p = 0.04, very low-quality evidence), and health care costs (SMD -0.32, 95% CI -0.5, -0.15, p < 0.001, very low-quality evidence).
  
  
  CONCLUSIONS
  Structured communication tools may improve documentation of EOL decision making and may result in lower resource use. The supporting evidence is low to very low in quality. Further high-quality randomized studies of simple communication interventions are needed to determine whether structured, rather than ad hoc, approaches to end-of-life decision-making improve patient-level, family-level, and system-level outcomes.
  
  
  BACKGROUND
  PROSPERO CRD42014012913.
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON, Canada. oczkowsj@mcmaster.ca.
authors.forename: Simon J W
authors.initials: SJ
authors.lastname: Oczkowski
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: Han-Oh
authors.initials: HO
authors.lastname: Chung
authors.affiliation: Canadian Hospice Palliative Care Association, Ottawa, Canada.
authors.forename: Louise
authors.initials: L
authors.lastname: Hanvey
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.|Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Mbuagbaw
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON, Canada.|Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: John J
authors.initials: JJ
authors.lastname: You
mesh_terms: D003142:Communication; D003661:Decision Support Techniques; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration; D010353:Patient Education as Topic / Q000379:methods*; D010358:Patient Participation / Q000379:methods*; D012121:Respiration, Artificial / Q000009:adverse effects*
keywords: Communication; Critical care; End-of-life; Ethics; Palliative care