Healthcare Providers' Perception of Advance Care Plans for Patients with Critical Illnesses in Acute-Care Hospitals: A Cross-Sectional Study


 BackgroundIt is unclear how healthcare providers provide advance care plans (ACPs) support to the patients treated in ICUs. The purpose of this study is to clarify healthcare providers’ perceptions of the ACPs support provided to patients receiving critical care in acute-care hospitals.MethodsA cross-sectional study was conducted using questionnaires. In this study, 400 acute-care hospitals with ICUs in Japan were randomly selected, and 1490 subjects, including intensivists, surgeons, ICU nurses, surgical floor nurses, and surgical outpatient nurses, participated. Survey items examined whether ICU patients received ACPS support, the participants’ degree of confidence in providing ACPS support, the patients’ treatment preferences and the decision-making process, and whether there was any discussion on and succession of values.ResultsResponses were obtained from 598 participants from 157 hospitals. Sixty-five hospitals (41.4%) reportedly supported ACPs provision to ICU patients. The subjects with the highest level of ACPs understanding were surgeons, 27 out of 59 (45.8%), and differences in understanding were observed across specialties (p < 0.001). Among the respondents, physicians and nurses expressed high levels of confidence in providing ACPs support to patients requiring critical care. However, 15.2% of all the subjects mentioned that they would not attempt to resuscitate the patients. In addition, 25.7% of the participants handed over patients’ values to other departments or hospitals, whereas 25.3% handed over the decision-making process.ConclusionsAmong the participating hospitals, 40% provided ACPs support to patients receiving critical care. This is probably because support providers lack ACPs knowledge and it is sometimes too late to start providing ACPs support after ICU admission. In addition, the perception of ACPs, widely considered an ambiguous concept, differs among healthcare providers. Finally, in acute-care hospitals with different healthcare settings, it is necessary to confirm and integrate the changes in feelings and thoughts of patients’ family members and healthcare providers.


Background
Often, patients receiving critical care experience the sudden onset of life-threatening symptoms. Advance care plans (ACPs) helps enable patients to live as per their wishes toward the end of their lives. Advance care plans contain advance directives (ADs), for example, do not attempt resuscitation (DNAR) and living wills, and ACPs is a process that concretises ADs by discussing patients' wishes regarding treatment, values, goals, and preferences [1]. However, currently, only inadequate ACPs support is provided to patients treated in intensive care units (ICUs) [2,3]. This may be the result of the unclear boundary between lifesaving and life-prolonging strategies in the critical care process. In addition, it is challenging to discuss ACPs among ICU patients, because the ICU is widely considered a place to receive life-saving treatment [4]. One of the problems faced by intensive care physicians is the accurate prediction of patients' prognoses [5]. It is reported that 50-60% of patients with DNAR in the ICU remained alive till discharge [6,7]. This suggests that aggressive treatment is effective in patients who are considered di cult to recover, which, in turn, indicates the di culty in predicting the likelihood of recovery of ICU patients. In addition, it is di cult to understand the perspectives of healthcare providers because it is widely recognised that the ICU is a place to provide life-saving treatment.
In addition, since the ICU is a place where patients undergoing sudden changes in their disease conditions are treated, it is di cult in many cases to con rm the patients' wishes regarding treatment; the implementation of ACPs in the ICU is complex, as well. In the ICU, patients are incapable of making decisions, and a surrogate decision-maker is required to provide necessary explanation and consent for DNAR [8][9][10]. Therefore, healthcare providers and surrogate decision-makers often decide on a transition from lifesaving to end-of-life medical care without considering the patient's wishes. The DNAR order speeds up this transition [11][12][13]. Another reason for the di culty in supporting ACPs for patients treated in acutecare hospitals and ICUs is the involvement of multiple practitioners. Patients who receive temporary surgical treatment or emergency transport at an acute-care hospital likely have more than one primary care physician and multiple attending physicians at the hospital. Moreover, patients with multiple diseases receive treatment from more than one expert physician. A study on patients with poor outcomes admitted to the ICU revealed con icts among intensivists, ICU nurses, cardiovascular surgeons, cardiothoracic surgeons, and neurosurgeons in determining the patients' treatment goals [14]. In this study, 60% of surgeons-intensive care physicians and surgeons, experienced con ict in determining the patients' end-oflife care policies within closed ICUs, where patient care policies are dictated by intensive care physicians.
One reason is the unique ICU management system, which may have more than one physician making decisions on a patient's treatment. In some circumstances, the provision of ACPs support, which usually involves only the patient and his or her primary physician, to ICU patients differs signi cantly from the recommended process. An essential aspect of ACPs is the process by which surrogate decision-makers and healthcare providers discuss and share DNAR and ADs regarding how patients live, what they value, and what they desire among themselves [15]. However, among patients receiving critical care, the process by which healthcare providers and patients share treatment values is currently inadequate, and DNAR decisions only have been focused [10][11][12][13]. Further, in acute-care hospitals, critically ill patients are treated by healthcare providers having different specialties and the treatment is generally not con ned to the outpatient, general ward, and ICU settings. In such hospitals, the manner in which a healthcare provider con rms and takes over a patient's wishes is considered an important aspect of the patient's treatment process. However, to date, no studies clarify the status of ACPs support provided to patients receiving critical care from the perspectives of multiple occupations and departments. By clarifying these ndings, one may realise important ways to support the provision of patient-centred care to patients receiving critical care in acute-care hospitals. In addition, it may be possible to clarify how to support patients based on their treatment processes and maintain the processes' continuity. Accordingly, the purpose of this study is to clarify healthcare providers' perception of ACPs support for patients receiving critical care in acutecare hospitals.

Study design
A cross-sectional study was conducted on acute-care hospitals with ICUs in Japan. As part of the study, a survey was carried out by distributing an anonymous self-recording questionnaire.
The survey period was from August to December 2019.

Participants
The criteria for participant selection were as follows: (1) Physicians working in an ICU as an intensive care specialist, (2) surgeons admitted to the ICU during the perioperative period (cardiovascular surgeons, thoracic surgeons, gastrointestinal surgeons, neurosurgeons, etc.), (3) nurses with at least 3 years of ICU experience, (4) nurses with at least 3 years of experience working in surgical wards, and (5) nurses with at least 3 years of experience working in surgical outpatient clinics.
Participants satisfying any of the following exclusion criteria were excluded: (1) Primary residents under training and (2) nurses in their rst or second year of employment.
In this study, statistical data were analysed using analysis of variance. An estimated correlation ratio of 0.05 and a detection power of 0.8 were set, and a total of 350 subjects, with 70 subjects from each department, were considered the target sample. The research targeted 400 randomly selected hospitals with ICUs in Japan. It was assumed that 30% of the participants could provide responses. Therefore, approximately 1-3 physicians, 5 ICU nurses, 5 surgical oor nurses and 1-3 surgical outpatient nurses were sampled per facility. Consequently, the subjects were 240 full-time ICU doctors, 240 surgeons, 400 ICU nurses, 400 oor nurses, and 240 outpatient nurses. The participants were selected at random by an ICU director, an ICU head nurse, a head nurse of a oor, and a head nurse of the outpatient department. Of these, the following were granted informal consent for surveys: 155 intensivists, 127 surgeons, 555 ICU nurses, 422 oor nurses, and 231 outpatient nurses and a total of 170 hospitals.

Data collection and statistical analysis
First, data collection was carried out by mailing a survey request form and a sample questionnaire to the managers of each department of the target hospitals. Subsequently, facility number was added in the order in which the survey approval was obtained, and the questionnaire was sent to the participants. Second, the questionnaire and a return envelope were sent to the subjects. The survey's purpose and method and the handling of personal information were explained in writing to each participant; further, after completing it, the participant sealed and returned the completed questionnaire by post. Questionnaire recovery was carried out by mail.
The main outcomes of this survey clari ed whether or not ACPs support was provided to prospective ICU patients. In addition, the survey examined how to obtain consent for DNAR, how often to obtain con rmation, how and when to con rm the wishes of prospective ICU patients, how to collaborate with other departments and institutions, and knowledge on ACPs. Participants' details, such as their age, gender, years of work experience, and designation, were collected, as well. Physicians and nurses evaluated the participants' professional quali cations. Further, oor nurses and outpatient nurses checked the department to which they belonged, and ICU nurses, intensivists, and surgeons examined the ICU management system. The ICU management system involved the following aspects: (1) A closed ICU is a facility where only intensivists make decisions on all the patients' treatment strategies. (2) In semi-closed ICUs, intensivists intervene for all patients in the ICU or for those patients in need. (3) An ICU without an intensivist was referred to as an open ICU.
The software IBM SPSS Statistics Ver. 25.0 was used for statistical analysis. After basic statistical analysis, normality was con rmed and descriptive statistics were performed. The difference in perceptions by occupation and the average difference between departments were obtained. Further, the existence of any signi cant difference among ve participants having different occupations and belonging to various departments was examined using one-way analysis of variance.
Tukey's multiple comparison test was performed whenever signi cant differences less than 5% were found. Further, when equal group variance could not be assumed, Welch's test was performed; when a signi cant difference at <5% was observed, Game-Howell's multiple comparisons were performed. The t-test was conducted to analyse two groups with different occupations and departments. Finally, the χ2 test was performed for the nominal scale, and the signi cance level was set as <5% (two-sided test). All statistical analyses were performed by supervising statisticians. Although there was no common characteristic among the prominent participants in each job category, intensivists and surgeons were more prevalent than others. The most frequently transitioned response to the transition of patient preferences and decision-making was "medical information such as treatment plans". <Insert Table 2 here> The degree of ACPs understanding was the highest (often and always), at 25%, for intensivists (P = 0.097) ( Table 3). Further, 27 surgeons (45.8%) were able to select the correct items for ACPs knowledge, with a signi cant difference (P < 0.001). The degrees of con dence of various participants in supporting ACPs provision to patients and their families were 48.8 ± 26.5, 46.9 ± 27.7, 34.6 ± 22.7, 38.5 ± 21.3, and 36.8 ± 27.1 for intensivists, surgeons, ICU nurses, oor nurses, and outpatient nurses, respectively (P = 0.016).
<Insert Table 3. Table4 here> Provision of decision-making support to patients and performance of cross-departmental information sharing by healthcare providers To the question whether the patients admitted to the ICU might be asked about their wishes to receive treatment, 32 (25.8%) intensivists, 11 (18.6%) surgeons, and 64 (35.0%) ICU nurses answered that the patients were asked often or always (p = 0.148) ( Table 5). In addition, the con rmation of treatment intention was most commonly performed when a new treatment was considered for all participants, followed by the time of disease progression. Among all healthcare providers, surgeons were the ones who most frequently con rmed patients' intentions. In the treatment intention content con rmed to the patient, the selection of treatment was the most abounding for all participants, and it was 80-90%; this was followed by the progress in disease prediction. The patients' values were ascertained by 72 (58.1%) intensivists, 27 (45.8%) surgeons, and 71 (38.8%) ICU nurses (P = 0.006). On the other hand, 53 (42.7%) intensivists, 35 (60.4%) surgeons, and 79 (44.6%) ICU nurses responded that their treatment always/often re ected the patients' wishes (p = 0.378).
<Insert Table 5 Table 6 here> Notably, 54 (43.9%) nurses in the surgical ward reported that they often or always consider their patients' values and wishes regarding treatment (Table 6). In addition, 80 (65.0%) oor nurses reported that they often or always share information on their patients' needs across wards. However, 53 (43.1%) participating oor nurses reported that they share their patients' needs, as well as the process that led to the decision. In addition, 20 (18.3%) nurses in the surgical outpatient department responded that they frequently shared patient information with the oor in which the patients were admitted. Therefore, the responses of 73 (67.0%), 51 (46.8%), and 50 (45.9%) participants were the surrogate decision-maker, contents of the crucial informed consent, and values and wishes of the patients regarding treatment, respectively.

Discussion
In the current study, 40% of the target hospitals provided ACPs support to ICU patients. This signi cantly adds to the literature since, to date, only a few studies have clari ed the status of ACPs support provision to ICU patients. In a survey on physicians involved in the treatment of patients undergoing cardiovascular surgery, most of whom were treated in the ICU, 85% of the physicians considered ADs to be useful, whereas 62% reported that they did not discuss the ADs with their patients since they were concerned that such discussions might make the patients anxious or afraid [16]. In a Japanese survey on physicians working in palliative care units, 62.6% of the respondents recommended Ads; however, only approximately 30.3% supported their patients [17]. This is because palliative care physicians prefer family-centred to patientcentred decision-making in end-of-life care planning. In general, research on ACPs and its effects has been conducted in patients with advanced cancer and in the eld of palliative care. However, it is suggested that ACPs is not yet widely accepted in these elds. Further, support for ACPs in ICU-treated patients is still under study, and relevant research has not yet revealed any de nite effects. On the other hand, one reason why ACPs support is not actively provided to critical care patients is that healthcare providers have only a low understanding of ACPs. The current study con rmed this understanding by revealing that many respondents across job categories and departments did not completely understand ACPs. Earlier studies indicate that although they understand the necessity of ACPs support for high-risk postsurgical and ICUtreated patients, they are aware of a lack of knowledge and skills to support ACPs [18,19]. The current study provides the same result and emphasises the importance of improving healthcare providers' recognition and understanding of ACPs in the future.
In addition, the healthcare providers who con rmed DNAR with patients ranged from 10-20%, and those who did not recon rm DNAR following the improvement of patients' conditions ranged from 10-50%.
According to earlier studies, the extent to which patients are involved in DNAR decision-making varies widely from 25% [20] to 82% [21]. Further, this involvement is often complicated by various factors, such as cultural aspects, situation, hospital policy, and individuals' behaviour [22]. In particular, surgical ward nurses and outpatient nurses tended not to recon rm their intentions regarding DNAR. Further, most often, DNAR was checked with patients following the worsening of their condition. These ndings suggest that a patient's recovery may reduce the need for ACPs and weaken the perception that patients want to be treated. Further, earlier studies reveal that preferences regarding end-of-life care change for patients who recover after ICU treatment [23], and healthcare providers nd it challenging to continue the discussion on patient preferences over the course of the treatment.
In addition, approximately 30% of the respondents opined that patients would select a surrogate decisionmaker, and the most common answer was that the surrogate was selected from among family members irrespective of the job category or department. The ACPs discussion process includes the selection of a surrogate decision-maker. However, it is not su ciently done in practice; therefore, it is often too late to ask the patient for a surrogate decision-maker, since the con rmation of the patient's intention to undergo treatment is generally made at the time of disease progression. Moreover, in some cases, a healthcare provider selects a surrogate decision-maker. In this respect, healthcare providers may not understand ACPs.
In addition, some patients do not select a surrogate; further, if a multi-death society is realised in the future, healthcare providers may have more opportunities to examine patients' best interests. Studies evaluating the effectiveness of established ACPs interventions point out that the processes, interventions, and metrics of caregivers and ACPs are inconsistent and very complex [24]. However, ACPs may share a patient's treatment wishes and requirements with a healthcare provider or a surrogate decision-maker and are worth being discussed on and addressed in advance for critical care patients who are at high risk of losing their decision-making capacity.
Patients who have undergone high-risk surgery and have been admitted to ICUs show willingness to discuss ACPs in advance to ensure that their treatment preferences are respected and to minimise the burden on family members toward the end of their life [23]. At the same time, an increasing number of healthcare providers are positively considering the provision of ACPs support to patients [17,25]. Therefore, in the future, the provision of ACPs support to critical care patients may be positively promoted by improving healthcare providers' knowledge and support skills.
Only approximately 20-30% of ICUs and 40% of wards and outpatients considered patients' wishes and values regarding treatment and implemented processes that realised their wishes and decisions. Further, it was pointed out that in acute-care hospitals where patients experience rapid changes in their disease conditions, their wishes regarding treatment/care and resuscitation might differ from those recorded on admission [26,27]. Moreover, in many cases, patients and physicians do not discuss resuscitation, and the associated needs of less than half the total number of patients are absent in medical records [28]. These suggest that shared decision-making processes involving physicians, patients, and healthcare providers are currently inadequate. There is concern that such decision-making increases the likelihood of patients receiving unwanted treatment, as well.
On the other hand, acute-care hospitals experience di culties in deciding when and by whom their patients' intentions should be con rmed. This is because the length of hospitalization is short, even for patients undergoing high-risk surgeries, and it is challenging for healthcare providers to identify the intentions of patients in severe conditions. Those who receive critical care are more likely to move to the end of life than those who do not. If patients enter the end of life, they should be provided high-quality medical care that satis es their preferences. It is necessary to ask the patients to elucidate their wishes regarding treatment and sense of value in advance at the time of hospitalization or starting treatment to initiate ACPs support provision. Instead of focusing only on end-of-life care, ACPs should encompass patients receiving all types of treatment. It may be necessary to develop tools that can improve the quality of communication among patients, their families, and healthcare providers without placing any additional burden on caregivers.
This study has some limitations. First, the sample size of surgeons considered in this study was small. The recovery rate was as low as 30% for all respondents except intensivists. In addition, although it was planned to investigate both the status of ACPs support for each job category and the response of each hospital, it was challenging to secure the participation of all the healthcare providers of a single hospital and this has not been adequately factored in in this study. However, by examining patients' perceptions of ACPs support from various roles involved in the care of patients receiving ICU treatment, future studies may help overcome the challenges involved in promoting ACPs support.

Conclusions
The provision of ACPs support to patients receiving critical care in acute-care hospitals was performed by 40% of the target hospitals. This suggests that most healthcare professionals lack appropriate understanding of the importance of ACP and that, in general, ACPs is initiated very slowly after ICU admission. Further, the perception of ACPs differs among healthcare providers and, hence, ACPs is an ambiguous support concept. The healthcare profession is different by health condition and place of care.
In acute-care hospitals where patients receive different treatments or the physicians who make treatment decisions change frequently, This suggests that most healthcare professionals lack appropriate understanding of the importance of ACPs and that, in general, ACPs support is initiated too late after ICU admission. These ndings suggest the need to develop processes that consider patients' wishes and decisions regarding treatment, tools that help inherit values, early education programs targeting patients, and appropriate supporters.

Declarations
Ethics approval and consent to participate The study was approved by ethics committees at St. Luke's International University(approval number: 19-A036), and conducted following the guidelines of the Declaration of Helsinki.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Competing interests