• Luyi Xu, Areej R El-Jawahri, and Emily B Rubin.
• Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, New York, New York; and.
• Ann Am Thorac Soc. 2021 May 1; 18 (5): 848-856.

AbstractRationale: Patients receiving prolonged mechanical ventilation experience high morbidity and mortality, poor quality of life, and significant caregiving and financial burden. It is unclear what is discussed with patients and families during the tracheostomy decision-making process.Objectives: The aim of this study was to identify themes of communication related to tracheostomy decision-making in patients receiving prolonged mechanical ventilation and to explore patient and clinical factors associated with more discussion of these themes.Methods: We conducted a mixed-methods study involving adult patients in medical or cardiac intensive care units who received continuous mechanical ventilation for ≥7 days and were considered for tracheostomy placement during the same admission. We performed a consensus-driven review of documented family meeting conversations to identify characteristics and themes related to tracheostomy decision-making. A multivariate analysis was performed to investigate patient and clinical factors associated with the discussion of one or more of the identified themes.Results: Of the 241 patients included, 191 (79.2%) had at least one documented conversation regarding tracheostomy decision-making, and 148 (61.4%) required further discussions before reaching a decision. We identified the following four themes related to tracheostomy decision-making: patient's previously expressed preferences, patient's baseline condition and functional status, long-term complications, and long-term prognosis. Of the documented conversations, 45.3% addressed none of the identified themes. Patients who did not undergo tracheostomy placement were more likely to have documented discussion of one or more themes compared with those who did (74.6% vs. 41.6%). In multivariate analysis, age ≥75, female sex, significant preadmission functional dependence, home oxygen requirement, and involvement of palliative care were associated with more documented discussion of one or more themes.Conclusions: Our findings suggest inadequate information exchange regarding patient preferences and long-term prognosis during tracheostomy decision-making, especially among patients who went on to pursue tracheostomy. There is a critical need to promote effective shared decision-making to better align tracheostomy intervention with patient values and to prevent unwanted health states at the end of life.

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