Shared decision making in critical care: a clinical reality and an ethical necessity

Abstract

OBJECTIVE: To formulate a theory of shared decision making in critical care that accounts for both the legal and ethical warrants for informed consent, and the roles of nurses and patients' family members in shaping decision making. METHODS: Review of relevant essays and books on informed consent and narrative theory, with emphasis on arguments about the limits of informed consent and the elements of narrative theory. FINDINGS: The theory of informed consent seems to apply to the model of a competent patient undergoing a simple procedure, but this model may not fit in the ICU for several reasons: Critical care is a process that unfolds over time. It includes a host of risks and involves a variety of persons such as nurses and families, and often the patient cannot participate in the decision. A review of the critiques of informed consent theory showed that the theory cannot adequately justify what risks should be disclosed to a patient and how the patient should understand those risks. This finding indicates a serious flaw that is all the more compelling in the setting of the ICU. Fortunately, narrative provides a theory for how the many persons involved can negotiate meaning to reach a shared decision. CONCLUSION: Informed consent occurs when the patient understands the facts; understanding adheres to meaning, and meaning is achieved through narrative. Thus, a theory of shared decision making that uses narrative resolves the problems of informed consent and substantiates the important roles of nurses and patients' families in critical care.