BMJ Open protocol maps decision aids for ICU and emergency end-of-life decisions
Decisions about life-sustaining treatment in emergency departments and intensive care units often unfold under severe time pressure, with incomplete prognostic information and families asked to speak for patients who cannot speak for themselves. In that setting, the design of a decision aid is not an abstract academic exercise; it can shape whether a family understands the tradeoffs between continuing invasive treatment, withholding treatment, or withdrawing treatment when ongoing care no longer matches the patient’s values.
This BMJ Open protocol sets out a scoping review focused on decision aids and related interventions used to support shared decision-making in emergency and intensive care settings. The review is designed to map what has already been studied, who the tools are meant to help, and how those tools have been delivered in high-stakes clinical environments where decisional capacity may be absent and surrogate decision-makers carry the burden of choice.
A single gap drives the project: decision aids have been examined extensively in chronic disease and other preference-sensitive decisions, but their use in end-of-life care during acute critical illness has not been comprehensively organized into one evidence map.
Why emergency and intensive care decisions strain shared decision-making
The protocol frames the problem with unusual clinical clarity. Emergency and intensive care clinicians frequently confront patients with rapidly changing physiology, uncertain recovery trajectories and limited opportunities for extended counseling. The decision itself may involve continuing aggressive support, limiting escalation, or shifting to comfort-focused treatment. Each path carries moral weight, and the stakes are highest when the patient cannot participate directly.
Shared decision-making offers a way to anchor these choices in patient values rather than in reflexive technological momentum. Decision aids are meant to support that process by presenting options, describing likely benefits and harms, and helping families or surrogates clarify what outcomes the patient would accept or reject. In an ICU, even a well-constructed aid has to work inside a compressed, emotionally charged conversation that may take place beside a ventilator, a monitor, or in a crowded emergency bay.
The review question is broader than a single tool format
The protocol does not limit itself to one narrow kind of intervention. It will include decision aids or related tools aimed at adult patients, family members, surrogate decision-makers, or healthcare professionals involved in life-sustaining treatment and end-of-life care decisions in emergency and intensive care settings. Quantitative studies, qualitative reports, mixed-methods research and descriptive studies are all eligible, which is appropriate for a field where the literature is likely to include both formal decision aids and practical communication tools.
Searches will be conducted in PubMed, Web of Science, the Cochrane Central Register of Controlled Trials, CINAHL and Ichushi-Web. English- and Japanese-language studies published from January 2000 onward will be considered. Two reviewers will independently screen studies, assess eligibility and chart the data, a standard approach that reduces the risk of selection bias in a literature base that may be sparse, heterogeneous or conceptually inconsistent.
The scope is deliberately inclusive. In an area this clinically fraught, a narrow search would miss tools that differ in form but not in function. Some interventions may be written handouts, some may be communication frameworks, and some may be structured prompts embedded in routine care. What matters for this protocol is whether the intervention was intended to support shared decision-making around life-sustaining treatment or end-of-life care.
A scoping review is the right design for an uneven evidence base
Scoping reviews are built for questions where the literature has not yet been consolidated into a single, mature evidence stream. That is exactly the position of decision aids in critical care end-of-life decision-making. A systematic review aimed at effect estimates would be premature if the underlying studies vary too much in format, target population, setting and outcome measurement. A scoping review can instead identify what exists, how the field has defined the intervention, and where the practical and conceptual gaps remain.
The use of Joanna Briggs Institute methodology and PRISMA-ScR reporting gives the project a structured framework. The planned descriptive synthesis should make it possible to see whether the literature is concentrated in a few countries, focused more heavily on family surrogates than on patients, or centered on particular decisions such as withholding treatment, withdrawal of treatment, or comfort-focused transitions. Those distinctions matter in critical care because a tool designed for one decision context may not translate cleanly to another.
A brief protocol can still have direct bedside relevance. If the review finds that the literature is fragmented across small, disconnected intervention types, that will tell clinicians and researchers that the field has not yet settled on a shared model of what a decision aid should look like in the ICU or emergency department. If the map shows repeated use of the same constructs, such as values clarification or option framing, it may reveal an emerging practical standard for future trials and implementation studies.
Ethics, dissemination and the clinical gap this review is meant to fill
No ethics approval is required because the project will use publicly available literature only. The findings are planned for publication in a peer-reviewed journal and presentation at scientific conferences.
The larger clinical issue remains immediate: in emergencies and intensive care, families are often asked to decide under grief, shock and uncertainty, while clinicians must act within minutes or hours. Decision aids cannot erase that pressure, but they may improve the quality of the conversation by making preferences, tradeoffs and realistic treatment goals easier to discuss. This protocol is a mapping exercise, not an outcomes trial, so it will not answer whether any specific tool improves survival, reduces conflict or changes treatment patterns.
What it can do is define the terrain more precisely. If the literature is thin, inconsistent or methodologically uneven, future research will need to build from that baseline before claiming that decision aids can reliably support end-of-life decision-making in the highest-acuity settings.