A systematic review and meta-synthesis of factors that influence clinical decision making for organ support interventions within the critical care unit

BackgroundThe critical care unit is a dynamic environment that necessitates a high volume of daily clinical decisions regarding organ support. It is known that decision-making varies significantly between clinicians, even where internationally accepted treatment guidance exists and overall the processes and influences on clinical decision-making are poorly understood. Our aim was to summarise the evidence on the decision-making process and the factors that influence organ support decisions in the critical care setting and 2) conduct a meta-synthesis to generate a model of medical decision-making, illustrating how different factors interact and affect the process. MethodsWe conducted a systematic search on three databases (PubMed, Embase and CINAHL) to find relevant papers exploring factors that influenced organ support decisions made by critical care clinicians. A meta-synthesis was then completed on included papers. The data were collated into a common format and cross-compared. This enable the generation of distinct themes/subthemes that were synthesised to develop a higher order interpretation. Results33 studies (from 8967 citations) met the inclusion criteria. 21 of these only included nurses, 7 only doctors and 5 were interprofessional. 11 factors that influenced a clinicians decision-making were identified: experience; professional and personal risk; uncertainty; characteristics of individuals; senior support; team hierarchy; decision making by colleagues; protocols, guidelines and evidence; time and workload; hospital structure; and clinical condition. These were grouped into four themes: human, team, system and patient factors. From our interpretation of the data, we found decision-making is often linear and primarily dictated by disease factors (i.e. patients clinical parameters). However, the identified human, team and system factors can place strain on decision-makers and make clinical scenarios more complex. There is scope however to modify these to optimise critical care decision-making. ConclusionWhile decision-making surrounding organ support is complex and dynamic, we identified recurring themes that influenced these decisions across different professions and environments. Further studies should focus on understanding how different decision-making processes directly affect patients outcomes.