Interprofessional Shared Decision-Making: Who Is at the Table?

To the Editor:

Collaboration of an interprofessional critical care team is integral for the successful care of this complex and vulnerable patient population (1). In a recently published article in Critical Care Medicine, Michalsen et al (2) provided five conditional recommendations from an expert panel consisting of ICU physicians, nurses, and bioethicists regarding appropriate actions for engaging in interprofessional shared decision-making (IP-SDM). We agree with the sentiments described by Michalsen et al (2); however, we feel it vital to highlight that a truly interprofessional critical care team consists not only of physicians and nurses but also of dietitians, case managers, clergy, ethicists, pharmacists, physical and occupational therapists, physiotherapists, psychologists, respiratory therapists, and others. The review examined medical, nursing, critical care, and bioethical journals but did not broaden the scope to include journals of other health professions, which may have excluded the valuable roles of these professions.

Indeed, just last month, Lee et al (3) published a systematic review and meta-analysis in Critical Care Medicine describing improvements in morbidity and mortality from pharmacist inclusion in interprofessional critical care teams. Evidence for improved outcomes with an interprofessional approach in the ICU is available for other professions as well (4). Thus, we argue that the principles outlined by Michalsen et al (2) should extend to all members of the interprofessional team. We suggest that each profession describe their involvement within the ICU team in relation to the five recommendations presented. We have provided a framework for pharmacists below:

RECOMMENDATIONS 1 AND 2

IP-SDM is defined as a collaborative process facilitating team involvement for clinical decision-making. IP-SDM should be used to make the most complex clinical decisions through combined rationale. The pharmacist’s role may be as members of the rounding ICU team collaborating with other disciplines to make critical pharmacotherapy decisions (e.g., initiation and discontinuation of antibiotics, vasopressor choice, analgesia and sedation selection). Pharmacists should be involved with all four levels of interprofessional collaboration, with examples of each level outlined below as follows:

1. Level 1 (Individual Decision): Pharmacist adjusts a patient’s electrolytes per hospital protocol based on morning labs

2. Level 2 (Information Exchange): Pharmacist relays past antimicrobial usage and culture reports to the intensivist on rounds for purposes of prescribing appropriate antimicrobials

3. Level 3 (Deliberation): The pharmacist on ICU rounds discusses with the attending physician whether to start vasopressin for septic shock. Ultimately, the attending makes the final decision

4. Level 4 (Shared Decision-Making): The pharmacist, intensivist, respiratory therapist, and nurse discuss the mechanical ventilation settings, sedation requirements, and physical examination findings for an intubated patient. The team jointly elects to extubate the patient

RECOMMENDATIONS 3 AND 4

These recommendations discuss the need for high-quality communication between the interprofessional team within the ICU. The pharmacist’s role may be to act as the point person for certain clinical conditions (e.g., sedation and delirium, antimicrobial management, and ICU prophylaxis). This creates an environment where pharmacists develop trust, initiate deliberation, and directly share in the final decisions and responsibility for clinical outcomes along with all ICU team members.

RECOMMENDATION 5

Additional studies evaluating IP-SDM for improving outcomes are needed. Pharmacists should take an active role in conducting future research on IP-SDM, which would align with current roles conducting clinical research and quality improvement initiatives aimed at reducing costs and improving patient outcomes (5).

The recommendations from Michalsen et al (2) highlight a key initiative in critical care to optimize collaborative efforts, and we encourage thoughtful incorporation of all professions in these types of recommendations.