| Objective:To investigate the decision-making conflict and decision-making preparation status of family members of ICU patients with acute kidney injury during CRRT,to understand the real experience of decision-making dilemma of family members of patients,and to understand the reasons for decision-making dilemma of family members of ICU patients during CRRT.Under the guidance of the Ottawa Decision Support Framework,and used the Delphi expert consultation method to develop the decision-making auxiliary tool and clinical implementation plan for the CRRT treatment of family members of ICU patients,so as to provide support and help for the CRRT treatment decision of family members of ICU patients,and provide reference for promoting shared decision-making in ICU.Methods:In the first phase,a mixed study approach was used to conduct a deep investigation of the current status of CRRT onboard treatment decisions of ICU patients’ families.For its quantitative study,a cross-sectional survey was used to select family members of patients in an intensive care unit care hospital in Taiyuan City who met the criteria for nadir of a tertiary during January 2022-August 2022,and the questionnaire mainly included: general information questionnaire,decision participation scale,decision-making preparation scale,and decision conflict scale.Statistical analysis was performed using SPSS 26.0,with p <0.05 as the test level.Statistical methods included: statistical description,statistical inference,one-way analysis of variance and multiple linear regression,and Pearson correlation analysis.In the qualitative study,15 family members of patients requiring CRRT in the ICU were selected for semi-structured interviews from June 2022 to August 2022 with a purposive sampling method and information saturation method.And use Nvivo 11.0 to store the data,and Colaizzi 7-step to analyze,summarize data,and refine the theme.The second phase used Delphi expert consultation to construct a decision aid for CRRT for patients’ families.The decision aid was based on the Ottawa Decision Support Framework,and the expert consultation was conducted in 2 rounds,and Excel 2019 and SPSS 26.0 were applied for analysis,and descriptive analysis was performed by frequency,coefficient of variation,significance assignment mean and standard deviation,etc.The effective return rate of the expert questionnaire was used to indicate the expert positive coefficient,the authority coefficient(Cr)was used to indicate the degree of expert authority,and the cardinality test was conducted by SPSS to analyze the degree of expert coordination.The third phase of the clinical pretest using decision aids,using usability scales tests its clinical usability and acceptability,interviews with all the families of patients who participated in the pretest to understand their feelings and experiences of using the decision aids.In this way,we continuously adjust the content of the decision aid and the clinical implementation plan,and improve the decision aid and clinical implementation plan to form the final decision aid for CRRT for families.Results:The cross-sectional results showed that the score of decision conflict of family members was(43.18±14.72),91.17% of patients’ family members had decision-making conflict;77.5%of the clinical decision type was passive,13.7% was active,and 8.8% was shared;the score of decision-making preparation was(51.57±15.43),68.63% of patients’ family members were underprepared;among them,decision-making conflict was negatively correlated with the type of expected decision-making(r=-0.358,P=0.000<0.05)and decision-making preparation(r=-0.484,P=0.000<0.05);multiple stepwise linear regression analysis showed that patients’ family members’ age,knowledge of CRRT knowledge,and readiness for decision making were significant influencing factors of decisional conflict.The qualitative study showed that the interviews with ICU patients’ families revealed that their CRRT decision dilemmas were complex,and three main themes were included:decision dilemma antecedents,decision dilemma content,and decision dilemma experience.The Delphi expert consultation resulted in a decision aid based on the Ottawa decision support framework for CRRT for family members which containing 6 primary indicators,13 secondary indicators,and 22 tertiary indicators;the experts enthusiasm in two rounds was100%,the authority coefficient in round were 0.841 and 0.891.The results were reliable with high authority of the experts and reliable consultation;the Kendall coefficient of concordance was 0.260 in round 1 and 0.357 in round 2(both P<0.000),which were statistically significant and great coordinated.Therefore,the decision support tool developed in this study is scientific.The results of the clinical pretest indicated that the usability and acceptability of the CRRT decision aid were great;usability(58.13±10.87)> 50,acceptability(8.87±0.88),and validity(9.00±0.89)points.The tool is informative,illustrated and easy to understand,which can help families compare different treatment modalities for selection,improve the efficiency of doctor-patient conversation,obtain effective information timely,etc.It can protect the family’s right to know and promote effective communication with doctors.Conclusion:In this study,the current survey found that families of ICU patients with decisionmaking conflict during continuous renal replacement therapy on board were at a moderate to high level.Age,understanding of CRRT,decisional preparation and clinical decisionmaking type were the main influencing factors.And the complexity of the CRRT decisionmaking content,lack of effective communication,urgent decision time,family,social,and economic influences,and fatigue and other factors have a significant impact on decisionmaking conflicts of family members.Medical staff should pay attention to the family’s state of decision-making conflict,and intervene to improve decision-making conflicts based on key influencing factors.The Decision aid for continuous renal replacement therapy based on the Ottawa Decision Support Framework is scientifically sound and reliable,and found to have some clinical usefulness after initial testing by the patient’s family.This aid enables timely identification of families with conflicting decisions and decision intervention,effectively helps families analyze the risks and benefits of different medical choices,improves their knowledge of patients’ illnesses and treatment techniques,clarifies personal values,improves decision-making conflicts,reduces decision-making delays,improves the quality of family decision-making and promotes high-quality clinical decision-making.With the development of bio-psycho-social medicine model,patients’ right to medical choice and informed consent in focus,and the patient-centered care medical model is deeply rooted.The Decision Aid for Continuous Renal Replacement Therapy integrates the concept of Share Decision-making in ICU clinical decision-making,takes full account of the special characteristics of ICU patients,pays attention to the ICU patients’ families’ decision-making conflicts,and applies decision aids to improve the clinical decision-making process of families based on a full understanding of their realistic needs,resulting in a CRRT decision aid intervention project that facilitates optimal decision-making by families.Further multicentre longitudinal studies will be conducted in the future to continuously improve the CRRT decision-aid intervention project and to gradually promote its use. |
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