Life-support decision making in critical care: Identifying and appraising the qualitative research evidence

Crit Care Med. 2009 Feb 24. [Epub ahead of print]
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Life-support decision making in critical care: Identifying and appraising the qualitative research evidence*
Giacomini M, Cook D, Dejean D.
From the Department of Clinical Epidemiology and Biostatistics (MG, DC);
Centre for Health Economics and Policy Analysis (MG, DD); Department of Medicine (DC); Health Research Methodology Programme (DD), McMaster University, Hamilton, ON, Canada.

OBJECTIVE:: The objective of this study is to identify and appraise qualitative research evidence on the experience of making life-support decisions in critical care. DATA SOURCES:: In six databases and supplementary sources, we sought original research published from January 1990 through June 2008 reporting qualitative empirical studies of the experience of life-support decision making in critical care settings.

STUDY SELECTION:: Fifty-three journal articles and monographs were included. Of these, 25 reported prospective studies and 28 reported retrospective studies. DATA EXTRACTION:: We abstracted methodologic characteristics relevant to the basic critical appraisal of qualitative research (prospective data collection, ethics approval, purposive sampling, iterative data collection and analysis, and any method to corroborate findings). DATA SYNTHESIS:: Qualitative research traditions represented include grounded theory (n = 15, 28%), ethnography or naturalistic methods (n = 15, 28%), phenomenology (n = 9, 17%), and other or unspecified approaches (n = 14, 26%). All 53 documents describe the research setting; 97% indicate purposive sampling of participants. Studies vary in their capture of multidisciplinary clinician and family perspectives. Thirty-one (58%) report research ethics board review. Only 49% report iterative data collection and analysis, and eight documents (15%) describe an analytically driven stopping point for data collection. Thirty-two documents (60%) indicated a method for corroborating findings.

CONCLUSIONS:: Qualitative evidence often appears outside of clinical journals, with most research from the United States Prospective, observation-based studies follow life-support decision making directly. These involve a variety of participants and yield important insights into interactions, communication, and dynamics. Retrospective, interview-based studies lack this direct engagement, but focus on the recollections of fewer types of participants (particularly patients and physicians), and typically address specific issues (communication and stress). Both designs can provide useful reflections for improving care. Given the diversity of qualitative research in critical care, room for improvement exists regarding both the quality and transparency of reported methodology.