Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU (PONDER-ICU)

Most critically ill patients want care that promotes the length and quality of their lives. Too often, their care focuses on only one of these goals. There is a mismatch between the care that patients want and the care they receive. This is because, sometimes, clinicians do not talk to patients about their goals and wants. Or, clinicians do not do it soon enough. This pragmatic, stepped-wedge, cluster-randomized trial tested two electronic health record interventions in 17 intensive care units (ICUs) at 10 hospitals. The interventions were designed to increase ICU clinicians’ engagement of critically ill patients and caregivers in discussions about alternative treatment options, including care focused on comfort. We hypothesized outcomes might improve by requiring ICU clinicians to assess patients’ prognosis at 6 months and provide a justification if they did not offer patients the option of comfort-oriented care.

This trial enrolled 3,500 patients on a breathing machine with chronic serious illness at high-risk of death. Nudging ICU clinicians to assess prognosis and/or offer comfort-focused treatment did not reduce patients’ length of stay in the hospital. They improved certain end-of-life outcomes without impacting rate of death. Simple nudges to ICU clinicians to promote communication around patients’ goals may improve end-of-life care outcomes for critically ill patients. Further work is needed to understand for which types of patients such nudges are most effective.

Atrium Health

The Donaghue Foundation