Contributors to quality in complex decision-making in paediatric intensive care

Multidisciplinary complex decision-making (CDM) has become a ubiquitous component of paediatric intensive care practice. Some complex decisions-including determining goals of care or initiating life-long technology dependence-can benefit from structured approaches to decision-making. To optimise implementation of a previously published CDM tool, we undertook a quality improvement project aiming to identify key process and contextual contributors to effective CDM from the perspectives of the non-intensive care unit clinicians.

A two-stage, institutionally registered quality improvement project was undertaken with multidisciplinary, non-paediatric intensive care unit (PICU) clinicians participating in CDM within a tertiary mixed PICU. An initial anonymous survey explored perspectives on communication and decision-making quality and processes, with categorical responses analysed quantitatively and free-text responses analysed thematically following Braun and Clarke's methodology. Survey findings informed subsequent semistructured focus group interviews with interested clinicians. Rigour was supported through independent coding and investigator and data-source triangulation.

Of 133 invited clinicians, 40 completed the survey in full (response rate: 30%). Most respondents were consultant medical practitioners (80%), and 93% reported prior participation in ad hoc, unstructured CDM with the PICU team. Although 87.5% reported comfort participating in CDM, respondents identified barriers including communication difficulties between teams (65%) and lack of clinician continuity of care (52.5%). Thematic analysis identified three primary domains influencing CDM: (i) care team structure; (ii) discussion planning and processes; and (iii) interpersonal communication and working culture. Focus groups identified priorities for implementation, including defined trigger criteria, appropriate representation, psychological safety, and clinically experienced neutral facilitation.

Multidisciplinary stakeholder perspectives revealed essential priorities for optimising CDM. Improving decision-making quality requires a multifaceted approach that supports intentional implementation of a deliberative tool with additional strategies addressing team care structures, communication, and working culture.