The Shared Document as a Tool for Shared Care Planning: A Retrospective Analysis of 160 Cases

Shared Care Planning (SCP) represents a collaborative decision-making process integrating advance care planning and shared decision-making to support ethically complex clinical pathways. Since 2016, the Clinical Ethics Consultation (CEC) service at the Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS (FPUG) in Rome has implemented SCP through the use of the Shared Document (SD) for healthcare ethics planning. This study aimed to describe the SD as an operational tool supporting SCP, focusing on its procedural characteristics, multidisciplinary dimension, and the ethical and contextual issues emerging during its implementation.

This single-center, retrospective observational study analyzed digitized medical records of patients who underwent SCP through the drafting of one or more SDs between 2016 and 2024 at FPUG. Data were extracted from SDs and clinical records in accordance with the RECORD guidelines. Variables included processing time, number of meetings with the clinical ethics consultant (CEc), number of healthcare professionals and family members involved, ethical-clinical issues, contextual challenges, and care orientations proposed within the SDs. Descriptive statistics were used to characterize the cohort and operational aspects of the service.

Among 454 patients referred to the CEC service, 154 patients underwent SCP, resulting in 160 SDs. The most frequent ethical issues concerned the proportionality of treatments to initiate (70%) and ongoing treatments (31%). Contextual issues emerged in 74% of cases, particularly pregnancy-related situations (44%) and absence of a legal guardian (19%). Drafting of SD required multiple interdisciplinary meetings (mean: 2.4), with an average processing time of 7 days. The number of healthcare professionals involved increased over time, reflecting growing multidisciplinary participation. The most frequent care orientations included palliative care (58%), withholding invasive/intensive maneuvers (34%), and indications for surgical or diagnostic treatments.

The SD emerged as a structured clinical-ethical tool supporting complex shared care planning processes beyond issues of informed consent alone. Its use facilitated multidisciplinary deliberation, the integration of ethical and contextual factors, and continuity in care planning across different clinical trajectories.