C17-07 Unrepresented Patient in the ICU: Identification and Communication During Interprofessional Team Rounds

Motivation

Unrepresented patients, defined as adults who lack decision-making capacity and have no available surrogate, pose well-documented, ethical, clinical, and operational challenges in hospital and intensive care unit (ICU) settings. Prior work highlights  delay  in care, uncertainty in decision-making, and increased burden  on clinicians and healthcare systems when no surrogate is available. However, existing literature has  largely focused  on prevalence, ethics,  and institutional decision-making  processes, with limited attention to how ICU teams recognize  and  communicate about the absence of a surrogate during routine interprofessional rounds.

 Methods

We conducted a secondary analysis  of the  AVIVA  dataset,  comprising  audio-recorded, transcribed, and annotated interprofessional ICU rounding discussions from  a  large  academic medical center. This dataset included 403 rounding discussions  representing  319 unique patients. Patients with documented decision-making capacity or an identified family member were excluded.  Unrepresented patients were operationally defined as those coded as having no identified family and unknown engagement.  Directed content analysis was used to  identify  relevant cases, followed by thematic analysis of dialogue during rounding discussions to explore how ICU teams discussed surrogate absence and related to decision-making and care planning.

Results

Twenty-six patients (8.2%) were identified as potentially unrepresented. Analysis of rounding discussions revealed recurring themes, including uncertainty  regarding  decision-making authority, delays in care planning or goals of care discussions,  predominantly reactive  communication in response to clinical deterioration, and expression of system-level burden, including clinician frustration and ethical discomfort. These themes, along with representative quotes, are displayed in Table 1.

Conclusion

Unrepresented patients  constitute  a meaningful subset of ICU admissions and are associated with distinct communication and decision-making challenges  during interprofessional rounds. These findings suggest that ICU rounds may  represent  an  underutilized  opportunity for  earlier identification of unrepresented patients and more proactive approaches to ethical, patient-centered decision-making and care planning. 

This abstract is funded by: None