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Intubation and Mechanical Ventilation for COPD^*

Development of an Instrument To Elicit Patient Preferences

^* From the Departments of Medicine (Drs. Dales, Hebert, and McKim, and Ms. Sullivan) and Nursing (Dr. O'Connor), University of Ottawa, Ottawa, Canada; and the Institute for Clinical Evaluative Sciences and The Clinical Epidemiology Unit (Dr. Llewellyn-Thomas), Sunnybrook Health Science Centre, Toronto, Canada.

Correspondence to: Robert E. Dales, MD, MSc, Ottawa General Hospital, LM17, 501 Smyth Rd, Ottawa, Ontario, K1H 8L6, Canada

Background: Whether to simply provide palliative care or to intubate and use mechanical ventilation (MV) in a patient with severe COPD in acute respiratory failure is a difficult decision. The outcome of MV cannot be accurately predicted. Some patients cannot be weaned from the ventilator; those who are weaned often return to chronic severe respiratory disability. It is important that patients participate in this decision, but assistance is required. To address these issues, we developed and pilot-tested an aid to assist patients with MV decisions.

Methods: A scenario-based decision aid was developed consisting of an audiocassette and a booklet describing intubation and MV and its possible outcomes. We used a probability tradeoff technique to elicit the patients' preferences and a decisional conflict scale to evaluate satisfaction.

Results: With the assistance of the decision aid, all patients (10 men and 10 women) reached a decision. Two men and all 10 women declined MV. Mean decisional conflict was low (2.2 of a possible 5; SD, 0.9). At 1 year, only two patients (11%) had changed their decision. The agreement between physicians and patients was 65%; between next-of-kin and patients, there was uniform disagreement.

Conclusion: With the decision aid, stable decisions were made with satisfaction and confidence. Proxy decisions were incongruent, especially when made by family members. The strong gender effect should be further investigated. We suggest that the COPD decision aid be further tested in a community clinical setting.

Key Words: advanced directives • COPD • decision making • mechanical ventilation

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