What Families Need and Physicians Deliver: Contrasting Communication Preferences Between Surrogate Decision-Makers and Physicians During Outcome Prognostication in Critically Ill TBI Patients
Authors
Quinn, ThomasMoskowitz, Jesse
Khan, Muhammad A.
Shutter, Lori
Goldberg, Robert J.
Col, Nananda
Mazor, Kathleen M.
Muehlschlegel, Susanne
UMass Chan Affiliations
Department of SurgeryDepartment of Anesthesiology/Critical Care
Department of Medicine
Meyers Primary Care Institute
Department of Quantitative Health Sciences
Department of Neurology (Neurocritical Care)
Document Type
Journal ArticlePublication Date
2017-10-01Keywords
Critical careDecision aid
Goals-of-care decisions
Qualitative research
Shared decision making
Surrogate decision-maker
Traumatic brain injury
UMCCTS funding
Critical Care
Health Communication
Health Services Administration
Nervous System Diseases
Neurology
Translational Medical Research
Trauma
Metadata
Show full item recordAbstract
BACKGROUND: Surrogate decision-makers ("surrogates") and physicians of incapacitated patients have different views of prognosis and how it should be communicated, but this has not been investigated in neurocritically ill patients. We examined surrogates' communication preferences and physicians' practices during the outcome prognostication for critically ill traumatic brain injury (ciTBI) patients in two level-1 trauma centers and seven academic medical centers in the USA. METHODS: We used qualitative content analysis and descriptive statistics of transcribed interviews to identify themes in surrogates (n = 16) and physicians (n = 20). RESULTS: The majority of surrogates (82%) preferred numeric estimates describing the patient's prognosis, as they felt it would increase prognostic certainty, and limit the uncertainty perceived as frustrating. Conversely, 75% of the physicians reported intentionally omitting numeric estimates during prognostication meetings due to low confidence in family members' abilities to appropriately interpret probabilities, worry about creating false hope, and distrust in the accuracy and data quality of existing TBI outcome models. Physicians felt that these models are for research only and should not be applied to individual patients. Surrogates valued compassion during prognostication discussions, and acceptance of their goals-of-care decision by clinicians. Physicians and surrogates agreed on avoiding false hope. CONCLUSION: We identified fundamental differences in the communication preferences of prognostic information between ciTBI patient surrogates and physicians. These findings inform the content of a future decision aid for goals-of-care discussions in ciTBI patients. If validated, these findings may have important implications for improving communication practices in the neurointensive care unit independent of whether a formal decision aid is used.Source
Neurocrit Care. 2017 Oct;27(2):154-162. doi: 10.1007/s12028-017-0427-2. Link to article on publisher's site
DOI
10.1007/s12028-017-0427-2Permanent Link to this Item
http://hdl.handle.net/20.500.14038/50346PubMed ID
28685395Related Resources
ae974a485f413a2113503eed53cd6c53
10.1007/s12028-017-0427-2
Scopus Count
Related items
Showing items related by title, author, creator and subject.
-
The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis: Phase 2 methodological reportNeogi, Tuhina; Aletaha, Daniel; Silman, Alan J.; Naden, Raymond L.; Felson, David T.; Aggarwal, Rohit; Bingham, Clifton O. III; Birnbaum, Neal S.; Burmester, Gerd R.; Bykerk, Vivian P.; et al. (2010-09-01)OBJECTIVE: The American College of Rheumatology and the European League Against Rheumatism have developed new classification criteria for rheumatoid arthritis (RA). The aim of Phase 2 of the development process was to achieve expert consensus on the clinical and laboratory variables that should contribute to the final criteria set. METHODS: Twenty-four expert RA clinicians (12 from Europe and 12 from North America) participated in Phase 2. A consensus-based decision analysis approach was used to identify factors (and their relative weights) that influence the probability of "developing RA," complemented by data from the Phase 1 study. Patient case scenarios were used to identify and reach consensus on factors important in determining the probability of RA development. Decision analytic software was used to derive the relative weights for each of the factors and their categories, using choice-based conjoint analysis. RESULTS: The expert panel agreed that the new classification criteria should be applied to individuals with undifferentiated inflammatory arthritis in whom at least 1 joint is deemed by an expert assessor to be swollen, indicating definite synovitis. In this clinical setting, they identified 4 additional criteria as being important: number of joints involved and site of involvement, serologic abnormality, acute-phase response, and duration of symptoms in the involved joints. These criteria were consistent with those identified in the Phase 1 data-driven approach. CONCLUSION: The consensus-based, decision analysis approach used in Phase 2 complemented the Phase 1 efforts. The 4 criteria and their relative weights form the basis of the final criteria set.
-
Shelter: Smartphone Bridged Socialized Body Networks for Epidemic ControlBai, Xiaole; Wang, Honggang; Fang, Hua (2011-02-01)We propose using information, computing and networking innovations to tackle epidemic control challenges.
-
Decision Aids and Shared Decision-Making in Neurocritical Care: An Unmet Need in Our NeuroICUsMuehlschlegel, Susanne; Shutter, Lori; Col, Nananda; Goldberg, Robert J. (2015-08-01)Improved resuscitation methods and advances in critical care have significantly increased the survival of patients presenting with devastating brain injuries compared to prior decades. After the patient's stabilization phase, families and patients are faced with "goals-of-care" decisions about continuation of aggressive intensive care unit care or comfort care only (CMO). Highly varying rates of CMO between centers raise the question of "self-fulfilling prophecies." Disease severity, the physician's communication and the family's understanding of projected outcomes, their uncertainties, complication risks with continued care, physician bias, and the patient's and surrogate's wishes and values all influence a CMO decision. Disease-specific decision support interventions, decision aids (DAs), may remedy these issues in the neurocritical care unit, potentially leading to better-informed and less-biased goals-of-care decisions in neurocritically ill patients, while increasing decision knowledge, confidence, and realistic expectations and decreasing decisional conflict and regret. Shared decision-making (SDM) is a collaborative process that enhances patients' and proxies' understanding about prognosis, encourages them to actively weigh the risks and benefits of a treatment, and considers the patient's preferences and values to make better decisions. DAs are SDM tools, which have been successfully implemented for many other conditions to assist difficult decision-making. In this article, we summarize the purposes of SDM, the derivation of DAs, and their potential application in neurocritical care.