Lack of patient-participation in the decision-making process is described in a recent study on ethical concerns and patient participation in patients with sepsis and septic shock . Of 300 decision-making preferences recorded, only a minority of patients (16%) received informed consent and more than half (53%) had a discussion of values that could affect their decisions. The most common reasons for not discussing values or obtaining informed consent were the difficulty in determining whether the patient was cognitively capable or whether the patient was in a critical medical condition. The authors concluded that the decision-making process in the ICU is dysfunctional. The authors of another study found that patients with sepsis and septic shock were more likely to have a discussion about goals of care . However, patients who were involved in the decision-making process were less likely to have treatment withdrawn or to have life-sustaining treatment withheld. In three studies, the authors found no effect of interventions on ICU and hospital mortality [547–549] and in one study, no difference in death, or in ICU or hospital stay . Lastly, the use of an ethics consultation service did not affect the proportion of patients who underwent a withdrawal of care from a study that was discussed in another recent article .
Selection bias in ICU studies may also be a factor. While most studies include patients with sepsis or septic shock, three studies have included only patients with shock [552–554]. While the studies of Brouwer et al. and Drouin et al. found no effect of ethics consultation on ICU mortality, the study by Drouin et al. found a beneficial effect of ethics consultation on ICU mortality in patients with sepsis and septic shock . Additionally, confounding factors may have influenced the findings in the studies. For example, Carson et al. randomized patients after at least 7 days of mechanical ventilation . The authors of the study by Brouwer et al. report that patients in the ethics consultation group had more severe vasopressor use and acidemia than those in the usual care group . In the study by Drouin et al., after ethics consultation, patients received more adrenaline and norepinephrine and the amount of norepinephrine varied by the day in the ICU . The authors found that the intervention improved the adequacy of norepinephrine titration.
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