Understanding Medical Decision Making for Hospitalized Unrepresented Patients: A Systematic Review

Details

• Personal Author:
  Caplan A ; Forster M ; Nolan A ; Walsh BC
• Description:
  INTRODUCTION Medical decision making is a process fraught with challenge and complexity. Although there are several vulnerable populations that need particular consideration during medical decision making, unrepresented patients pose a unique challenge. An unrepresented patient is one who is unable to communicate their treatment preferences and lacks a surrogate to advocate on their behalf. In operationalizing a best interest standard, there unfortunately exists heterogeneity in both state statutes as well as recommendations from professional societies. This heterogeneity, combined with unique vulnerabilities to receive under or over treatment, create ethical concerns of equitable treatment. Our understanding of medical decision making in this population remains incomplete. Our objective was to perform a systematic review to assess who makes medical decisions for hospitalized unrepresented patients. While prior reviews have been broad in scope, ours exclusively focuses on determining who is involved in medical decision making for hospitalized unrepresented patients. Methods Our prospective systematic review strategy was submitted to Prospero. To best capture the heterogeneous description of unrepresented patients, our search terms included 21 variations 'unrepresented patient' across MEDLINE, EMBASE, PsycINFO, Web of Science, & CINAHL databases. Articles were included if they were in English, aged 18 years or older, hospitalized, and were unrepresented. Manuscripts were excluded if they were an editorial, case report, abstract, review, newspaper article, if study population did not include patients residing in the United States, not written in English, and if the capacity assessment was for research. A primary review of the title and abstract by one author (BCW) excluded manuscripts if they definitively did not include unrepresented patients. A second full text review required independent concurrent inclusion by two authors (BCW & MF), with a third deciding disagreements (AN). Exclusion during full text review will also be noted. Results Our comprehensive search strategy found 7,148 manuscripts. Alter removing 1,038 duplicates, 5,713 were excluded in the primary review because their study population was definitively not unrepresented. The majority of these excluded articles tested decision concordance between a patient and surrogate, or another aspect of decision making. The remaining 397 will be assessed by full text. We will focus on which agents are involved in medical decision making for hospitalized unrepresented patients. Conclusions Unrepresented patients present a unique challenge for providers who must choose what decision making process is optimal for their patient. Careful analysis of prior work is paramount for future studies to contribute in a meaningful way. [Description provided by NIOSH]
• Subjects:
  Decision Making Delivery Of Health Care Occupational Health Safety
• Keywords:
  Decision Making Health Standards Medical Care Medical Treatment Systematic Reviews
• ISSN:
  1073-449X
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Abstract or Summary
• Place as Subject:
  New York ; OSHA Region 2
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Volume:
  201
• NIOSHTIC Number:
  nn:20066341
• Citation:
  Am J Respir Crit Care Med 2020 May; 201(Abstract Issue):A6612
• Email:
  b.corbett.walsh@nyumc.org
• Federal Fiscal Year:
  2020
• Performing Organization:
  New York University School of Medicine
• Peer Reviewed:
  False
• Start Date:
  20170701
• Source Full Name:
  American Journal of Respiratory and Critical Care Medicine
• Supplement:
  Abstract Issue
• End Date:
  20260630
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:a9db2b6ed0922de402580ec3b5922002655d81c191b0483d01ec163031b702923ac59630784a517c22c012ea58f501d25975110ae67a9c16c65205010857376d
• Download URL:
  https://stacks.cdc.gov/view/cdc/212809/cdc_212809_DS1.pdf
• File Type:
  [PDF - 209.28 KB ]