Domain 1 - Patient and Family Centered Decision Making
- Recognize the patient and the family as the unit of care:
- Assess and document who comprises the family; it may not be a traditional one.
- Assess the patient's and family's decision-making style and preferences:
Address conflicts in decision making within the family and between staff and
- Clarify and document level of participation patient and/or family desire in choosing
- Explicitly address conflicts that arise within families and help families resolve
- Explicitly address conflicts that arise between staff and family members.
- Train staff in conflict resolution techniques.
- Assess together with appropriate clinical consultants, the patient's capacity to
participate in decision-making about treatment and document assessment.
- Initiate advance care planning with the patient and family:
- Take the lead in involving patient and/or family in treatment decisions by convening
a family conference with members of the health care team and available family members.
If patient is able to participate, hold conference at the bedside.
- Clarify and document the status of the patient's advance directive:
- If the patient has completed an advance directive, review with the patient and/or
family upon admission to the ICU and document discussion
- Place the advance directive in the chart and "flag" the chart.
- Identify the health care proxy and surrogate decision-maker:
- For patients who lack decision-making ability, assess and document the family's
knowledge of the patient's verbal wishes and goals about treatment.
- Clarify and document resuscitation orders:
- Distinguish do-not-resuscitate (DNR) orders from withholding and withdrawing life-sustaining
treatment; policies and guidelines for these should be distinct.
- Document discussions with patient and/or family about cardiopulmonary resuscitation
- Utilize preprinted "family discussion sheet" where informal and formal discussions
with family members may be documented.
- Assure patients and families that decision making by the health care team will incorporate
- Follow ethical and legal guidelines for patients who lack both capacity and a surrogate
- Establish a written policy detailing these guidelines.
- Establish and document clear, realistic and appropriate goals of care in consultation
with the patient and family:
- Ensure that treatments reflect the goals of care.
- Identify a time frame for the reassessment of treatment goals and set up follow-up
meetings with the patient and/or family to discuss progress towards goals.
- Help the patient and family assess the benefits and burdens of alternative treatment
choices as the patient condition changes.
- Forgo life-sustaining treatments in a way that ensures patient and family preferences
are elicited and respected:
- Develop pathways to improve the quality of care in the setting of withdrawing life-sustaining
Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation
dedicated to long-term changes in health care institutions to substantially improve
care for dying people and their families.