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

Inadequate communication between clinicians and critically ill patients and families often leads to care that does not match what patients want. For this reason, guidelines recommend that clinicians discuss prognosis and all reasonable treatment options, including the option of care focused solely on comfort, with critically ill patients and families at risk of poor outcomes. Yet, this communication often occurs late in critical illness or not at all.

We conducted a large real-world clinical trial to test two electronic health record (EHR) interventions in 17 intensive care units (ICUs) at 10 hospitals. The interventions were designed to increase ICU clinicians’ engagement of critically ill patients and/or their families in discussions about alternative treatment options, including care focused on comfort.

The two interventions were each compared with usual care alone and combined. The first intervention asked clinicians to assess and document patients’ prognosis at 6-months (prognosis group); the second asked them to document whether a comfort-focused treatment alternative was offered or a reason why not (treatment alternative group).

We hypothesized that clinical outcomes would improve by nudging ICU clinicians in the EHR to assess patients’ prognosis at 6 months and provide a justification if they did not offer patients the option of comfort-oriented care.

Among the 3500 patient encounters enrolled in this study, observed hospital mortality was 36% and the median observed length of stay was 8.93 days.

This study found that electronically nudging ICU clinicians to document prognosis and offer a treatment alternative of comfort-focused care, alone or in combination, did not reduce hospital length of stay. However, nudging ICU clinicians to offer a treatment alternative of comfort-focused care led to an increase in hospice enrollment (10.9% vs 7.3%) and earlier comfort care order (3.6 vs 4.5 days after enrollment) compared to usual care, without increasing hospital mortality.

Lead authors of this study concluded that a simple, low-cost nudge to ICU clinicians to follow best practice guidelines and offer reasonable treatment alternatives to continued life-support led to improvements in the timing and quality of end-of-life care for critically ill patients who ultimately would not have survived.

To learn more, listen to Drs. Kate Courtright and Scott Halpern discuss the study on the GeriPal podcast.

Atrium Health

The Donaghue Foundation