In ICU, Need for Documentation Must Be Balanced with Caring for Patients

Newswise — A new study shows shortcomings in documentation of decisions regarding withholding or withdrawal of life support for patients dying in the intensive care unit (ICU). But that doesn't necessarily mean that patients aren't receiving thoughtful and attentive end-of-life care, according to an editorial in the September issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

"A patient can receive perfect medical care, whereas the documentation may have flaws,' according to the editorial by Drs. Armand R.J. Girbes of VU Medical Center, Amsterdam, and Jan G. Zijstra of University Medical Center Groningen, The Netherlands. They outline steps that may help to balance ICU doctors' responsibilities for documentation with their first priority: providing care for critically ill patients and their families.

Study Shows Problems with Documentation of Decisions to Forgo Life Support

The editorial comments on a new research study showing incomplete documentation of decisions regarding end-of-life care for patients at two Dutch ICUs. In that study, led by Dr. Peter E. Spronk of Gelre Hospital, Apeldoorn, most patients had orders regarding the withholding or withdrawal of life-supporting treatments at the time they died.

However, documentation of these decisions was "poor and inconsistent." Important information on decisions regarding end-of-life care was frequently missing from the medical records—for example, patient preferences regarding life support were recorded in less than one-fourth of cases. In about one-third of cases, there was no record of which ICU team member was involved in end-of-life decision making with the patient and family.

While good documentation of end-of-life decisions is essential, Drs. Girbes and Zijstra emphasize that patients in the study may still have received excellent care, despite the gaps in recordkeeping. Doctors face "a constant competition" between the need to talk to the patient and family and their responsibility to write and document what they do. "We should not document for the sake of documentation but first define the purpose and then create the documentation," the authors write.

Improve Documentation, but Keep Focus on Patient Care

Drs. Girbes and Zijstra outline some key goals of documentation, including communication of medically relevant information. This is especially important in the ICU, where it is critical to ensure continuity of care between the many doctors, nurses, and other professionals involved in patient care. And yet, no matter how good the documentation, some information is inevitably lost when one doctor hands off care to another.

Another important goal is to provide data for patient monitoring and diagnosis. In today's high-tech ICUs, a great deal of information is collected by automated systems. Yet doctors still must write down their diagnostic and treatment considerations, conversations with the patient, and physical examination findings. As demonstrated by the new study, "Patient data management systems do not improve documentation of more complicated processes."

Other goals of documentation include ensuring and improving the quality of care and protecting against legal liability. However, "To prevent lawsuits through documentation is almost an unreachable target," Drs. Girbes and Zijstra write.

They call for efforts to define a "minimum dataset"—deciding which data, considerations, and decisions are important enough to be recorded—as an important first step in assessing the adequacy of documentation. Once this is done, steps can be taken to identify and remedy the deficiencies of the documentation system. Drs. Girbes and Zijstra conclude, "Documentation is important but should be performed without losing sight of the purpose": taking care of patients and families.

About the IARSThe International Anesthesia Research Society is a nonpolitical, not-for-profit medical society founded in 1922 to encourage, stimulate, and fund ongoing anesthesia-related research and projects that will enhance and advance the anesthesiology specialty. The IARS has a worldwide membership of 15,000 physicians, physician residents, and others with doctoral degrees, as well as health professionals in anesthesia-related practice. In addition to publishing the monthly scientific journal Anesthesia & Analgesia, the IARS sponsors an annual clinical and scientific meeting, funds anesthesia-related research, and sponsors the SAFEKIDS research initiative in conjunction with the FDA. Additional information about the society and the journal may be found at www.iars.org and www.anesthesia-analgesia.org.

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