Analysis of the current situation and influencing factors of decision-making conflicts among alternative decision-makers in critically ill patients after cardiac surgery: a cross-sectional study

doi:10.21203/rs.3.rs-3583322/v1

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Analysis of the current situation and influencing factors of decision-making conflicts among alternative decision-makers in critically ill patients after cardiac surgery: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-3583322/v1

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Objective

This study aims to examine the prevailing state of decision-making conflict among alternative decision-mkers in postoperative critically ill cardiac surgery patients and analyze the factors that contribute to this conflict.

Methods

A convenience sampling method was employed to select 200 postoperative critically ill cardiac surgery patients and their substitute decision-mkers from a tertiary-level hospital in Shandong Province, between September 2023 and November 2023. The survey subjects were assessed using a general information questionnaire,family inpatient communication Survey, and the scale of the decisional engagement.

Results

The study found that substitute decision-mkers of postoperative critically ill cardiac surgery patients had a mean decision conflict scale score of (15.59 ± 8.58) and a standardized score of (24.36 ± 13.42). Among the substitute decision-mkers,7.5% had a medium level of decision conflict, while 51% had a high level of decision conflict. Correlation analysis revealed a negative correlation between the decision conflict level of alternative decision-mkers and the communication status of inpatient family members (r=-0.238, p < 0.01), as well as a negative correlation with the expectation level of participation in decision making (r=-0.195,p < 0.01);The results of the multiple linear regression analysis indicate that several factors significantly influenced the decisions made by substitute decision-mkers.These factors include whether the patient was admitted to the hospital for the first time, the decision maker's awareness of the patient's condition, the level of Decisional Engagement, and the communication status of the hospitalized patient's family members.

Conclusion

Decision-making conflicts among alternative decision-mkers in postoperative critically ill cardiac surgery patients are prevalent and influenced by various factors.

cardiac surgical procedures

critically ill patients

alternative decision-makers

decision conflict

influence factors

A critically ill patient refers to an individual who is at risk of or has already developed a severe medical condition, or whose vital signs are unstable, necessitating immediate specialized treatment or monitoring ^[1].These patients often lack the capacity to make decisions on their own due to the intricacy and rapid fluctuations of their condition, as well as the use of interventions such as mechanical ventilation and sedation, thereby requiring a surrogate decision maker to determine appropriate treatment options^{[2, 3]}.The patient frequently experiences decision-making challenges as a result of being mechanically ventilated and sedated. Moreover, the intricate nature and arduousness of decision-making in such patients, coupled with the limited availability of decision support, often elicit intense negative emotions or decision-making burden in alternative decision-makers, consequently causing delays and conflicts in the decision-making process. These conflicts not only significantly impact the decision-maker's physical and mental well-being but also contribute to delays in decision-making. The presence of decision-making conflict has detrimental effects on the quality of decision-making, impairs the patient's treatment process, and influences the final outcome for the patient^{[4, 5]}.This conflict not only poses significant risks to the decision maker's physical and mental well-being, but also results in delayed decision-making, diminished decision quality, hindered patient treatment, and compromised patient outcomes. Consequently, it is imperative to investigate the factors that contribute to decision-making conflict in substitute decision-mkers for critically ill patients, with the aim of developing a decision-support program for subsequent stages. The objective of this study is to examine the present state of decision-making conflict and the factors that influence substitute decision-makers in postoperative critically ill cardiac surgery patients. The aim is to offer healthcare professionals valuable insights to implement tailored interventions that enhance healthcare services and improve the overall experience of medical treatment for decision-makers.

1.1 Subjects of the survey

The convenience sampling method was employed to select substitute decision-mkers for critically ill patients who were admitted to a tertiary hospital in Jinan, Shandong Province, between September 2023 and November 2023 following cardiac surgery. The inclusion criteria for both patients and their substitute decision-mkers were as follows: (1) The participants in this study fulfilled the diagnostic criteria for critical illness, as determined by a scoring system known as the Acute Physiology and Chronic Health Evaluation II (APACHE II), with a score of greater than 15 points^[6]. (2) patients were admitted to the intensive care unit (ICU) for a minimum duration of 24 hours, exhibiting impaired consciousness and a Glasgow Coma Scale (GCS) score of 8 points or less. (3) All of them were >18 years old.(4) Responsible for signing the informed consent for patient's treatment.(5) Able to complete the questionnaire independently.(6) Voluntarily participated in this study. Exclusion criteria: (1) those who gave up resuscitation.(2) those with severe hearing impairment or verbal communication disorders.(3) those with a family history of genetic mental illness. This study was a cross-sectional survey study, and according to the requirements of statistical variable analysis, the sample size of the study on the factors influencing the variables was at least 5-10 times the number of variables^[7]. This study encompassed a comprehensive set of 18 study variables, accounting for a 10% sample attrition rate, necessitating a minimum of 99-198 samples. Ultimately, the final sample size for this study consisted of 200 cases. All investigators provided informed consent and willingly participated in the study, which received approval from the Ethics Committee of Biomedical Research Involving Human Beings of Shandong Provincial Hospital.(SWYX:NO.2023-523)

1.2 Survey instruments

1.2.1 General information questionnaire

The selection of predictors in this study was informed by a comprehensive review of both domestic and international literature, as well as consultations with relevant experts. The researcher developed a questionnaire encompassing various aspects, including general patient information (such as gender, age, and hospital admission history) and general substitute decision maker information (such as gender, age, education level, marital status, monthly household income, relationship with the patient, occupation type, awareness of the patient's disease, and place of residence).

1.2.2 Decision Conflict Scale

The decision conflict scale (DCS) was effectively developed by Canadian nursing scholar O'Connor in 1995 to assess the degree of decision conflict experienced by patients during hospitalization^[8]. Additionally, the family version of the decision conflict scale (FDCS) was derived from the DCS by Chinese scholars Liao Zongfeng^[9]. The scale utilized in this study was developed based on the Decisional Conflict Scale (DCS) and underwent testing to assess its reliability and validity within families of neurological ICU inpatients. This self-assessment scale was designed specifically for alternative decision-mkers involved in the care of hospitalized patients. Comprising of 16 items, the scale is divided into three dimensions: decision uncertainty (4 items), factors contributing to decision uncertainty (5 items), and perceived validity of the decision (7 items). Each item is scored on a 5-point Likert scale, ranging from "Strongly Agree" to "Strongly Disagree" in descending order. Each participant's response was evaluated using this 5-point Likert scale. All scores were standardized using the following formula: total score = sum of items scores /16*25. The resulting total scale score ranged from 0 to 100. A transformed total score below 25.0 indicated a valid decision with no conflict. Scores between 25.0 and 37.5 suggested a medium level of decision conflict, while scores above 37.5 indicated a high level of decision conflict, suggesting that participants experienced delays in their decision-making process. A higher score for the substitute decision maker indicated a higher level of decision conflict. .The Cronbach's alpha coefficient of the scale in this study is 0.888.

1.2.3 Inpatient Family Communication Scale

The Family Inpatient Communication Survey (FICS) is a measurement tool specifically designed for assessing the level of satisfaction among family members of hospitalized patients who lack decision-making capacity, regarding the quality of communication pertaining to medical decisions. The scale was developed by Torke^[10] team in 2016, and later developed by our scholars Li Jie^[11]. The scale was culturally adapted to suit the Chinese context and subsequently assessed for its dependability among families of intensive care unit (ICU) inpatients. Comprising a total of 30 items, the scale was categorized into two dimensions: information support (consisting of 18 items) and emotional support (comprising 12 items). Each item was evaluated using a 5-point Likert scale, ranging from "strongly disagree" to "strongly agree", with scores ranging from 1 to 5. The cumulative scores for each item were then summed to obtain a total score, ranging from 30 to 150. Higher scores on the scale indicated greater satisfaction among family members regarding the efficacy of medical communication. The satisfaction of the patient's family with the impact of medical communication is positively correlated with higher scores. The Chinese version of the scale demonstrated a Cronbach's alpha coefficient of 0.926 and a content validity index of 0.952. In this study, the Cronbach's alpha coefficient for the Chinese version of the scale was 0.921.

1.2.4 Decisional Engagement Scale

Decisional Engagement Scale (DES-10) was developed by American scholars Hoerger^[12]and compiled in 2016. It was later Chineseized by our scholars Wang Liping^[13]Sinicized it to evaluate the subjects' expectation of participating in medical decision-making. It comprises four dimensions, encompassing a total of ten entries. These dimensions include the decision empowerment dimension (consisting of three entries), information needs dimension (consisting of three entries), disease acceptance dimension (consisting of two entries), and future planning dimension (consisting of two entries). Each entry is rated on a scale ranging from 0 to 10, representing the degree of disagreement to agreement. The scores for each entry are then summed to obtain a total score. with higher scores indicating a greater expectation of participation in medical decision-making. The Cronbach's alpha coefficient for the Chinese version of the scale was found to be 0.850, indicating a high level of internal consistency. Additionally, the content validity index was determined to be 0.900, suggesting that the scale effectively measures the intended construct.

1.3 Data collection and quality control methods

The present study was undertaken by the researcher who developed a questionnaire based on the content of each scale. The electronic questionnaire was then distributed through the questionnaire platform for data collection. Additionally, an informed consent form was included, and all questionnaire items were designated as mandatory, ensuring that respondents could only submit their responses once all questions were completed. This measure aimed to guarantee the integrity of the questionnaire completion. Furthermore, IP addresses were restricted to prevent duplicate submissions.. Prior to commencing the survey, the researchers underwent comprehensive training on the fundamental concepts encompassed in the questionnaire, the guidelines, and potential challenges that may arise during the survey procedure. This training aimed to guarantee that each researcher could provide a precise and consistent interpretation of the survey's content. During the survey, the respondents were initially briefed on the study's objectives, the survey methodology, and the principle of confidentiality. Only after the respondents fully comprehended and consented, they were instructed to scan the QR code via the WeChat platform to access the official response platform and during the questionnaire completion process, respondents were individually addressed regarding any queries they had. Subsequently, a survey was conducted on-site to assess the reliability of the questionnaire, identifying and rectifying any errors or omissions through prompt communication with the respondents. On the final day of data collection, two researchers meticulously examined the collected data to ensure its accuracy, and error-free data was subsequently entered into Excel. The study involved the distribution of 200 questionnaires on-site, resulting in the recovery of 200 valid questionnaires, indicating a 100% retrieval rate for valid responses.

1.4 Methods of statistical analysis

The data processing and analysis in this study were conducted using SPSS 25.0 statistical software. For measurement data that followed a normal distribution, descriptive statistics were employed, including mean ± standard deviation for description, independent sample t-test for comparison between two groups, and analysis of variance (ANOVA) for comparison between multiple groups. Median and quartiles were used to describe measurement data that did not follow a normal distribution. Count data were described using frequency and constitutive ratios. The conformity of data to a normal distribution was assessed using the K-S test, and descriptive statistics were applied for the general information, decision conflict, family inpatient communication, and decisional engagement scores of patients and decision substitutes. Pearson correlation analysis was employed to examine the correlation among decision conflict, family inpatient communication, and decisional engagement. Variables that exhibited statistical significance in the one-way mid-analysis were subsequently considered as independent variables in the multiple linear stepwise regression analysis, with an alpha level of 0.05 for inclusion and 0.10 for exclusion. A significance level of P<0.05 was utilized to indicate statistical significance.

2.1 General information on survey respondents

2.1.1 General information about the patients:

This study involved the investigation of a cohort comprising 200 critically ill patients who had undergone postoperative procedures. Among these patients, 108 (54%) were identified as male, while 92 (46%) were identified as female. The majority of the patients fell within the age range of 45-60 years old, accounting for 120 individuals (60%). The subsequent age group of 18-44 years old consisted of 41 patients (20.5%), while the remaining 39 patients (19.5%) were over the age of 60. The mean age of the cohort was calculated to be 49.36±13.42. Furthermore, in terms of admission history, 115 patients (57.5%) had previously been admitted, while 85 patients (42.5%) were experiencing their first admission.

2.1.2 General information about the substitute decision-mkers:

This study examined a sample of 200 alternative decision-mkers for critically ill patients, comprising 110 males (55%) and 90 females (45%). The age distribution revealed that 92 cases (46%) fell within the 18-44 age group, followed by 88 cases (44%) in the 45-60 age group. The cultural level of the respondents predominantly ranged from junior high school to university, accounting for a total of 175 cases (87.5%). The majority of alternative decision-mkers were married, with 161 cases (80.5%) falling into this category. In terms of monthly family income, the most common range was 3000-6000, encompassing 123 cases (61.5%).; In terms of the relationship with the patient, it was found that the majority of cases involved the patient's children, accounting for 78 cases or 39% of the total. Additionally, 61.5% of the cases were attributed to the patient's children. Furthermore, the family monthly income of 3,000 to 6,000 was predominantly observed in 123 cases, representing 61.5% of the sample. Regarding the relationship with the patient, the majority of cases involved the patient's children (39%) or spouses (33.5%), with parents accounting for 15% of the cases and other relationships accounting for 12.5% of the cases. In terms of occupational type, the sample consisted of 60 cases of farmers (30%), 55 cases of workers (27.5%), 39 cases of individuals (19.5%), 24 cases of institution/retired individuals (12%), and 22 cases of other occupations (11%). In 65% of the 200 cases involving substitute decision making, the individuals assuming decision-making authority were uninformed about the patient's condition. Furthermore, in the majority of instances (60%), the place of residence for these cases was urban.

2.2 The present state and univariate examination of decision-making conflicts among alternative decision-mkers for patients in critical condition

The Alternative Decision Maker Decision Conflict Scale score was found to be (15.59±8.58), with a standardized score of (24.36±13.42). Among the various components of decision conflict, the highest score was observed for decision stress (6.85±4.19), followed by perceived decision validity (5.16±4.20), and decision values (3.59±3.24) had the lowest score. Out of the 200 substitute decision-mkers, 58.5% exhibited some level of decision conflict. Specifically, 105 (51%) of the substitute decision-mkers reported a moderate level of decision conflict, while 15 (7.5%) experienced a high level of decision conflict. The findings from the univariate analysis of decision conflict among substitute decision-mkers in critically ill patients are presented in Fig1and continue with Fig1

2.3 An examination of the correlation between decision conflicts among alternative decision-mkers and family communication and decision participation.

The communication scale score for families of hospitalized patients was found to be (117.63±16.40). Specifically, families expressed higher levels of satisfaction with the information support dimension, scoring (71.81±11.23), while their satisfaction with the emotional support dimension was relatively lower, scoring (45.82±6.34). The score for the decision participation scale was (89.24±8.40). Pearson correlation analysis revealed a significant negative correlation (r=-0.238, p<0.01) between the total score of the Decision Conflict Scale and the total score of inpatient family communication in this study.; A significant negative correlation was observed between the total score of the Decision Conflict Scale and the total score of the Decision Participation Scale (r=-0.195, p<0.01). Additionally, a significant positive correlation was found between the total score of the Inpatient Family Communication Scale and the total score of the Decision Participation Scale (r=0.199, p<0.01). Detailed results can be found in Fig 2.

2.4 This study employs multiple linear regression analysis to examine the various factors that influence decision-making conflicts among substitute decision-mkers in critically ill patients.

The dependent variable in this study was the decision conflict scores of alternative decision-mkers for critically ill patients. The independent variables used in the multiple linear regression analyses were the statistically significant variables identified in the univariate analysis. The inpatient family communication scores and decision participation scores were included in the regression analyses using their original values. The specific assignments of the independent variables can be found in Fig 3. The findings indicated that the admission status of the patient, the awareness of the substitute decision maker regarding the patient's condition, the communication within the inpatient family, and the level of participation in decision-making significantly influenced the degree of conflict in the substitute decision maker's decision-making process. These factors collectively accounted for 16.8% of the total variance, as presented in Fig4.

3.1 Conflicts

arising from decision-making among substitute decision-mkers are more commonly observed in critically ill patients.

The findings of this study indicate that a significant proportion (58.5%) of alternative decision-mkers experience decision conflict. Among these individuals, 51% exhibit a medium level of decision conflict, while the remaining 7.5% demonstrate a high level of decision conflict. Notably, the prevalence of decision conflict among alternative decision-mkers surpasses that reported by Miller’s ^[14]study, which is similar to our scholars Wu^[15] research results are similar. The reasons may be that Miller ^[14] did not restrict the severity of the patient's condition, whereas the chosen sample for this research employed alternative decision-mkers for critically ill individuals, suggesting a heightened seriousness and intricacy of the patient's condition. Consequently, this circumstance is likely to augment the complexity and discord in the decision-making process to a certain degree. Additionally, the advancement of foreign decision aid tools has reached a more advanced stage, enabling decision-mkers to access comprehensive information that facilitates the formulation of astute, efficacious, and well-informed decisions. In addition, most of the decision-mkers in this study are married, and the decision-mkers have to bear the burden of family and face the pressure of work, and the multiple roles make them face more decision-making pressure^[16] .Furthermore, a significant proportion of the participants in this study are married and thus have to shoulder the responsibilities of their families while also dealing with work-related pressures. These multiple roles contribute to an increased level of decision-making pressure experienced by the participants. The primary factor leading to decision-making conflicts among alternative decision-mkers in this study is the perceived pressure associated with making decisions. This pressure may stem from the limited knowledge that many alternative decision-mkers possess regarding the patient's condition, making it challenging for them to determine the potential advantages or disadvantages of their decision-making choices for the patient. It is advisable for healthcare professionals to promptly evaluate the extent of decision-making conflict among substitute decision-makers, and utilize international medical decision-making resources to furnish decision-makers with pertinent information and assist families in making suitable decisions.

3.2 The level of decision conflict experienced by substitute decision-makers is positively correlated with the patient's initial hospital admission and the limited knowledge available regarding the patient's condition.

The findings of this study indicate that decision-mkers who lacked familiarity with their patients' medical history and those whose patients were being admitted for the first time experienced a significant degree of decision conflict during the process of making clinical decisions. These results align with the research conducted by Alden’s ^{[17, 18]} study. One possible explanation for this phenomenon could be the limited capacity of decision-mkers to promptly assimilate the patient's condition, particularly in cases where patients are newly admitted to the hospital or are undergoing emergency cardiac surgery, such as aortic coarctation. The combination of a brief duration of patient admission, the severity of the patient's critical condition, and the necessity for an alternative decision maker to expedite the decision-making process may contribute to a heightened level of decision-making conflict. As the decision maker's knowledge regarding the patient's disease increases, along with their exposure to disease-related education and medical information, the analysis of the treatment plan's advantages and disadvantages becomes more lucid, subsequently enhancing the decision maker's confidence in their decision-making abilities^[19]. Consequently, when the decision maker is presented with a greater amount of medical information, the clarity of the assessment regarding the pros and cons of the treatment alternatives intensifies, leading to heightened confidence in their decision-making capabilities. Consequently, the likelihood of accurately estimating outcomes is augmented. Hence, the greater their ability to accurately assess the patient's post-surgical prognosis, leading to reduced decision-making conflicts. Consequently, it is recommended that healthcare professionals enhance their professional expertise while also gauging the level of disease knowledge among patients and decision-mkers. In cases where patients are newly admitted to the hospital or decision-mkers possess limited disease knowledge, medical staff can employ decision aids like pamphlets, videos, and other resources. This study aims to utilize evidence-based medical information to facilitate comprehension of treatment options among family members, enhance communication between patients and doctors, mitigate decision-making uncertainty, bolster decision-making confidence, minimize decision-making conflict, and ultimately enhance the overall quality of decision-making.

3.3 There exists a positive correlation between the degree of dissatisfaction among families of hospitalized patients regarding communication pertaining to medical decision-making and the intensity of conflicts arising from decision-making processes.

The findings of this study indicate a negative association between the decision conflict level of alternative decision-mkers and their satisfaction with medical communication. Specifically, individuals who reported lower satisfaction with medical communication experienced higher levels of decision conflict. Additionally, the correlation coefficient between the decision conflict scale and the emotional support dimension was found to be the strongest, with a value of r=-.273 (P < 0.05). Insufficient emotional support for the decision maker is prone to diminishing communication satisfaction and engendering decision conflict. Prior research has indicated that the communication proficiency of intensive care unit (ICU) nurses is deficient, particularly when compared to nurses in other general departments^[20]. Consequently, this deficiency contributes to decreased satisfaction with medical decision-making. There are several factors contributing to this issue, such as a noisy communication environment, significant nurse burnout, and a heavy workload^[21]. Hence, it appears that enhancing the communication proficiency of clinical medical personnel is a pressing concern. it is advisable for medical staff to proactively inquire about decision-makers' decision-making requirements, offer assistance in resolving their issues, thereby fostering a positive patient-physician rapport, bolstering decision-makers' trust in the medical staff, and subsequently augmenting their inclination to engage in discussions regarding the patient's condition with the medical staff. In order to mitigate nurses' work pressure, enhance the professional knowledge and communication skills of ICU nurses, enhance clinical decision-making communication satisfaction, and minimize alternative decision-making conflicts, it is imperative for nursing managers to judiciously allocate human resources.

3.4 As the expectations of alternative decision-mkers to engage in decision making decrease, there is a corresponding increase in the level of conflict experienced in their decision making process.

The findings of this study demonstrate a negative correlation between the degree of decision conflict experienced by alternative decision-mkers and their level of expectation for participation in decision-making processes. Specifically, a decrease in the expectation of alternative decision-mkers to partake in decision-making activities is associated with an increase in their level of decision conflict. This is consistent with the results of Pecanac ^[22–24] .The underlying cause of this phenomenon lies in the inverse relationship between the expectations held by substitute decision-mkers regarding medical communication and the amount of information support they receive pertaining to the disease. Consequently, this dynamic engenders heightened uncertainty surrounding the treatment, evident negative emotional states, and an elevated degree of decision conflict. The decision effectiveness dimension exhibited the strongest correlation coefficient with the expectation of participation in medical decision making, as measured by the decision conflict scale (r=-0.227; P < 0.05). This finding suggests that a decrease in the expectation of involvement in medical decision making is associated with reduced communication between the decision maker and medical staff, as well as limited access to information regarding the patient's condition. Consequently, the decision maker may experience uncertainty regarding the potential benefits or drawbacks of their decision for the patient. This implies that healthcare professionals ought to consider the values of decision-mkers during medical decision-making processes, attentively heed their requests when feasible, demonstrate respect for their decision-making preferences, offer additional medical knowledge, foster the involvement of decision-mkers in clinical decision making, enhance their motivation to engage in clinical decision making, and mitigate the extent of decision-making conflicts they encounter.

The issue of decision conflict among alternative decision-mkers for critically ill postoperative cardiac surgery patients is a matter of great urgency within the medical community. This study reveals that the level of decision conflict is particularly elevated in patients who were initially admitted to the hospital, decision-mkers with limited understanding of the patient's condition, lower anticipation of involvement in clinical decision making, and diminished satisfaction with communication regarding medical choices. Hence, it is imperative for healthcare practitioners to accord priority to these decision-mkers and implement decision support strategies aimed at facilitating the active involvement of patients in decision-making processes, mitigating decision conflicts, enhancing decision quality, and fostering harmonious doctor-patient relationships. However, it is important to acknowledge that this study is limited in scope as it is a cross-sectional investigation conducted solely within a single hospital setting. It is recommended that a future multi-center longitudinal study be conducted to examine the extent of decision conflict and the factors that influence alternative decision-mkers of patients with critical illness following cardiac surgery at various stages of the postoperative period. This study aims to establish a scientific foundation for the development of interventions targeting decision conflict.

Acknowledgments

The author is very grateful to her mentor Yang Lijuan for her guidance on this article, as well as to Shi Yanan,Zhang Renjie,and Shao Mei for their management of the data in this article.

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

This article has no funding support.

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Analysis of the current situation and influencing factors of decision-making conflicts among alternative decision-makers in critically ill patients after cardiac surgery: a cross-sectional study

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