Chest
Volume 116, Issue 3, September 1999, Pages 792-800
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Ethics in Cardiopulmonary Medicine
Intubation and Mechanical Ventilation for COPD: Development of an Instrument To Elicit Patient Preferences

https://doi.org/10.1378/chest.116.3.792Get rights and content

Background

Whether to simply provide palliative care or to intubate and use mechanical ventilation (MV) in a patient with severe COPD in acute respiratory failure is a difficult decision. The outcome of MV cannot be accurately predicted. Some patients cannot be weaned from the ventilator; those who are weaned often return to chronic severe respiratory disability. It is important that patients participate in this decision, but assistance is required. To address these issues, we developed and pilot-tested an aid to assist patients with MV decisions.

Methods

A scenario-based decision aid was developed consisting of an audiocassette and a booklet describing intubation and MV and its possible outcomes. We used a probability tradeoff technique to elicit the patients' preferences and a decisional conflict scale to evaluate satisfaction.

Results

With the assistance of the decision aid, all patients (10 men and 10 women) reached a decision. Two men and all 10 women declined MV. Mean decisional conflict was low (2.2 of a possible 5; SD, 0.9). At 1 year, only two patients (11%) had changed their decision. The agreement between physicians and patients was 65%; between next-of-kin and patients, there was uniform disagreement.

Conclusion

With the decision aid, stable decisions were made with satisfaction and confidence. Proxy decisions were incongruent, especially when made by family members. The strong gender effect should be further investigated. We suggest that the COPD decision aid be further tested in a community clinical setting.

Section snippets

Development of the MV Information Scenario

Fifteen respirologists from the Ottawa area were interviewed to determine the type of information exchanged between physicians and their patients about the prognosis of COPD, the ventilation process, and possible outcomes of MV.24 The interviews were tape-recorded and transcribed, and content analysis of the qualitative data was performed2526 to identify themes that were then incorporated into the decision aid. The information was reviewed for completeness and accuracy by members of the

Results

Twenty of 21 consecutive patients who were approached agreed to participate in the study; only 1 patient refused to complete the entire interview process. One patient did not want to commit to the time and energy required for the interview. All the patients were cared for by six specialists, with no one physician accountable for > 30% of these patients. The average length of the interviews was 79 min (range, 50 to 138 min). The patients were equally divided by gender (10 men, 10 women), had an

Discussion

In summary, we developed and applied an information scenario and a probability trade-off technique. Together, these elements constituted a proposed decision aid designed to provide information, describe choices, and allow patients with severe COPD to express the strength of their convictions concerning MV. We attempted to evaluate this decision aid from three different perspectives. Below, we first discuss this study in terms of its original motivation, and then we examine the extent to which

COPD (Emphysema)

COPD stands for chronic obstructive pulmonary disease. It is often called emphysema or chronic bronchitis, and it is a common disease that affects the lungs. When a patient has COPD or emphysema, the air passages in the lungs become narrow. This makes it difficult to get air in and out, like breathing through a straw.

Even though the patient does not feel sick, he or she might have trouble breathing and become short of breath very easily.

How Does COPD Affect Daily Life?

COPD affects the way a person performs his or her daily

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    Drs. Hebert and O'Connor are Career Scientists of the Ontario Minister Of Health. Dr. Llewellyn-Thomas is a National Health Research Scholarsupported by the National Health Research and Development Program.

    This research was funded in part by the Ontario Thoracic Society.

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