IS A DECISION AID DESIGNED TO FACILITATE SHARED DECISION MAKING ABOUT ADVANCE CARE PLANS FEASIBLE TO USE IN OUTPATIENT CLINICS? RESULTS FROM FEASIBILITY TESTING OF INFORMEDTOGETHER

Purpose: We report the outcomes of feasibility testing of a decision aid (DA) designed to facilitate shared decision making about invasive mechanical ventilation versus comfort measures only in the event of respiratory failure for severe COPD patients. 

Methods: We enrolled 22 patients with severe COPD and 8 clinicians, and observed 22 clinician-patient outpatient clinic visits in which InformedTogether was provided for use. Patient participant inclusion criteria were: diagnosis of severe COPD, age > 18 and English fluency. Clinician participants were Pulmonologists, Geriatricians and Respiratory Therapists.  Patient participants completed pre-post questionnaires; clinic visits were audio-recorded and transcribed, and; clinicians completed post-visit questionnaires. Primary outcomes included changes in: knowledge, motivation to make an advance directive, and decisional conflict. Secondary outcomes included questions measuring perceived acceptability of using InformedTogether in outpatient clinics. Paired t-test or nonparametric Wilcoxon Signed Rank test was used to compare pre-post scores for knowledge, motivation to make an advance directive and decisional conflict.

Results: There was a statistically significant improvement in mean knowledge score after using the DA (mean difference 3.47; sd 3.10, p value <0.0001). There was no statistically significant difference in the motivation to make an advance directive (mean difference 0; sd 0.57, p value=1). For Decisional Conflict, there was a trend toward less decisional conflict after using the DA, although the mean difference in pre-post scores was not statistically significant (mean difference -13.63; sd 21.67; p-value 0.0629). Of the 13 acceptability questions, 95% of patient participants gave strongly positive responses indicating that the decision aid was usable in the visit with their clinician, and that they would recommend the DA to others. Of the clinician participants, almost all decided to use most of the DA with the patient participants, and took an average of 15-20 minutes to use the DA. One clinician declined to use the DA. Most gave strongly positive responses to acceptability questions.

Conclusion: The InformedTogether DA is feasible to use in an outpatient clinic setting to initiate discussions about invasive mechanical ventilation versus comfort measures and advance directives for patients with severe COPD. Patient participants experienced increase in knowledge about treatment choices in the event of respiratory failure after using InformedTogether, and both patient and clinician participants supported the use of InformedTogether for other patients with severe COPD.