Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study
Authors
Ge, ConnieGoss, Adeline L.
Crawford, Sybil L.
Goostrey, Kelsey
Buddadhumaruk, Praewpannarai
Shields, Anne-Marie
Hough, Catherine L.
Lo, Bernard
Carson, Shannon S.
Steingrub, Jay
White, Douglas B.
Muehlschlegel, Susanne
UMass Chan Affiliations
Department of SurgeryDepartment of Anesthesia/Critical Care
Department of Graduate School of Nursing
Department of Neurology
Document Type
Journal ArticlePublication Date
2022-02-21Keywords
brain injuriescommunication
critical care
decision-making
family
goals
prognosis
treatment outcome
Diagnosis
Health Communication
Health Services Administration
Health Services Research
Nervous System Diseases
Nursing
Metadata
Show full item recordAbstract
IMPORTANCE: Withdrawal-of-life-sustaining treatments (WOLST) rates vary widely among critically ill neurologic patients (CINPs) and cannot be solely attributed to patient and family characteristics. Research in general critical care has shown that clinicians prognosticate to families with high variability. Little is known about how clinicians disclose prognosis to families of CINPs, and whether any associations exist with WOLST. OBJECTIVES: Primary: to demonstrate feasibility of audio-recording clinician-family meetings for CINPs at multiple centers and characterize how clinicians communicate prognosis during these meetings. Secondary: to explore associations of 1) clinician, family, or patient characteristics with clinicians' prognostication approaches and 2) prognostication approach and WOLST. DESIGN SETTING AND PARTICIPANTS: Forty-three audio-recorded clinician-family meetings during which prognosis was discussed from seven U.S. centers for 39 CINPs with 88 family members and 27 clinicians. MAIN OUTCOMES AND MEASURES: Two investigators qualitatively coded transcripts using inductive methods (inter-rater reliability > 80%) to characterize how clinicians prognosticate. We then applied univariate and multivariable multinomial and binomial logistic regression. RESULTS: Clinicians used four distinct prognostication approaches: Authoritative (21%; recommending treatments without discussing values and preferences); Informational (23%; disclosing just the prognosis without further discussions); advisory (42%; disclosing prognosis followed by discussion of values and preferences); and responsive (14%; eliciting values and preferences, then disclosing prognosis). Before adjustment, prognostication approach was associated with center (p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists; p = 0.001), patient age (p = 0.08), diagnosis (p = 0.059), and meeting length (p = 0.03). After adjustment, only clinician specialty independently predicted prognostication approach (p = 0.027). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). WOLST was more likely in older patients (p = 0.059) and with more experienced clinicians (p = 0.07). Prognostication approach was not independently associated with WOLST (p = 0.198). CONCLUSIONS AND RELEVANCE: It is feasible to audio-record sensitive clinician-family meetings about CINPs in multiple ICUs. We found that clinicians prognosticate with high variability. Our data suggest that larger studies are warranted in CINPs to examine the role of clinicians' variable prognostication in WOLST decisions.Source
Ge C, Goss AL, Crawford S, Goostrey K, Buddadhumaruk P, Shields AM, Hough CL, Lo B, Carson SS, Steingrub J, White DB, Muehlschlegel S. Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study. Crit Care Explor. 2022 Feb 21;4(2):e0640. doi: 10.1097/CCE.0000000000000640. PMID: 35224505; PMCID: PMC8863127. Link to article on publisher's site
DOI
10.1097/CCE.0000000000000640Permanent Link to this Item
http://hdl.handle.net/20.500.14038/34492PubMed ID
35224505Related Resources
Rights
Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBYNC- ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.Distribution License
http://creativecommons.org/licenses/by-nc-nd/4.0/ae974a485f413a2113503eed53cd6c53
10.1097/CCE.0000000000000640
Scopus Count
Except where otherwise noted, this item's license is described as Copyright © 2022 The Authors.
Published by Wolters Kluwer Health,
Inc. on behalf of the Society of
Critical Care Medicine.This is an
open-access article distributed under
the terms of the Creative Commons
Attribution-Non Commercial-No
Derivatives License 4.0 (CCBYNC-
ND), where it is permissible to
download and share the work provided
it is properly cited. The work
cannot be changed in any way or
used commercially without permission
from the journal.