Abstract
Aims and Objectives: To identify and explore the perceived experiences of nurses and physicians with incorporating an automated clinical decision support system in their critical care practices.
Background: Technological advancement has created ethical practice dilemmas in critical care settings. Information technology and statistical analyses have the potential to both further complicate and to contribute to the resolution of changing practice patterns.
The decision support technology used by participants in this study was the Cerner Acute Physiological, Age and Chronic Health Evaluation (APACHE) III system. The key function of this type of system is to predict the outcomes of decisions made in real life situations. The Cerner APACHE III provides decision support for situations such as: patient transfer and triage, life sustaining treatments, ventilation, hemodialysis, or the discontinuation of certain treatments.
Design: Descriptive interview-based design using qualitative methods.
Methods: Thirty-three healthcare clinical professionals working in a large U.S. medical center participated in in-depth interviews to describe their experiences integrating a clinical decision support system into their nursing or medical practices.
Results: Participants had strongly positive and negative impressions related to decision support system use in clinical practice. Participants opposed use of the computer as a “final decision maker” for patient care decisions, and had concerns about the issues of resource allocation so that insurers might acquire access to system information and use it to deny services or payments to patients. Some participants felt that it was unethical or unprofessional to withhold system statistical predictions from patients and family members.
Conclusions: The issues underlying critical care clinicians’ support or rejection of decision support technology must be examined more carefully to better define how to use this tool to optimally benefit patients and families and to better understand how use of these systems are influencing nursing or medical decision-making.
Clinicians in this study discussed their desire for transparency regarding use of the CSSD information, and provision of all information available as a way of supporting the autonomy of the family as they participated in end-of-life decisions. The consistent theme through all of the interviews was patient-family advocacy. Reservations about the use of CSSD were based primarily on the principle of non-malfeasance. This demonstrates that patient care remains the central priority of the healthcare team.
Relevance to Clinical Practice: Using clinical decision support systems impacts health care practitioners’ professional sensitivities as nurses or physicians in highly variable and often idiosyncratic ways. Dialogue between the professions of medicine and nursing could facilitate mutual understanding. Whether and how clinical decision support system analytic data are communicated to family members engaged in shared decision making regarding the withdrawal of life sustaining technologies depends on individual family circumstances.
Keywords: Clinical decision-making, clinical guidelines, multiprofessional practice, end-of-life decision-making, information technology, critical care
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