IMPORTANCE Misperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical information. OBJECTIVE To determine the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs). DESIGN, SETTING, AND PARTICIPANTS Mixed-methods study comprising quantitative surveys and qualitative interviews conducted in 4 ICUs at a major US medical center involving surrogate decision makers and physicians caring for patients at high risk of death from January 4, 2005, to July 10, 2009. MAIN OUTCOMES AND MEASURES Discordance about prognosis, defined as a difference between a physician's and a surrogate's prognostic estimates of at least 20%; misunderstandings by surrogates (defined as any difference between a physician's prognostic estimate and a surrogate's best guess of that estimate); differences in belief (any difference between a surrogate's actual estimate and their best guess of the physician's estimate). RESULTS Two hundred twenty-nine surrogate decision makers (median age, 47 [interquartile range {IQR}, 35-56] years; 68% women) and 99 physicians were involved in the care of 174 critically ill patients (median age, 60 [IQR, 47-74] years; 44% women). Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related to both misunderstandings by surrogates and differences in belief about the patient's prognosis; 38 (17%) were related to misunderstandings by surrogates only; 7 (3%) were related to differences in belief only; and data were missing for 12. Seventy-five patients (43%) died. Surrogates' prognostic estimates were much more accurate than chance alone, but physicians' prognostic estimates were statistically significantly more accurate than surrogates' (C statistic, 0.83 vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163; P = .008). Among 71 surrogates interviewed who had beliefs about the prognosis that were more optimistic than that of the physician, the most common reasons for optimism were a need to maintain hope to benefit the patient (n = 34), a belief that the patient had unique strengths unknown to the physician (n = 24), and religious belief (n = 19). CONCLUSIONS AND RELEVANCE Among critically ill patients, discordant expectations about prognosis were common between patients' physicians and surrogate decision makers and were related to misunderstandings by surrogates about physicians' assessments of patients' prognoses and differences in beliefs about patients' prognoses.

Background Problems persist with surrogate decision making in intensive care units, leading to distress for surrogates and treatment that may not reflect patients’ values. Objectives To assess the feasibility, acceptability, and perceived effectiveness of a multifaceted, nurse-led intervention to improve surrogate decision making in intensive care units. Study Design A single-center, single-arm, interventional study in which 35 surrogates and 15 physicians received the Four Supports Intervention, which involved incorporating a family support specialist into the intensive care team. That specialist maintained a longitudinal relationship with surrogates and provided emotional support, communication support, decision support, and anticipatory grief support. A mixed-methods approach was used to evaluate the intervention. Results The intervention was implemented successfully in all 15 patients, with a high level of completion of each component of the intervention. The family support specialist devoted a mean of 48 (SD 36) minutes per day to each clinician-patient-family triad. All participants reported that they would recommend the intervention to others. At least 90% of physicians and surrogates reported that the intervention (1) improved the quality and timeliness of communication, (2) facilitated discussion of the patient’s values and treatment preferences, and (3) improved the patient-centeredness of care. Conclusions The Four Supports Intervention is feasible, acceptable, and was perceived by physicians and surrogates to improve the quality of decision making and the patient-centeredness of care. A randomized trial is warranted to determine whether the intervention improves patient, family, and health system outcomes.

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The purpose of this study was to examine the effects of social cues in self-presentations and the congruence of other-generated comments with the self-presentation in people's evaluations of a profile owner. A 2 (level of social cues: high vs. low) × 2 (congruent vs. incongruent) × 2 (order) × 2 (multiple messages) mixed-subject experiment was conducted with 104 college students. The results showed that a profile owner was perceived less socially attractive when other-generated comments were incongruent with the profile owner's self-presentation. No matter how people package themselves with extravagant self-presentations, it cannot be very successful without validation from others. Interestingly, an interaction effect between congruence and the level of social cues suggested that perceived popularity was low in the incongruent condition regardless of level of social cue. Theoretical and practical implications were also discussed.

The emergence of online communication reflects a shift in communication practitioners’ roles, with more emphasis on interactive features in news such as writing online comments and clicking “like” on such comments. A 2 (consistency: consistent crisis responsibility attribution between online news and online comments vs. inconsistent responsibility attribution) × 2 (heuristic cues: high vs. low number of “likes” clicked) mixed subject design was tested on N = 389 samples. The findings of this study showed that participants tended to attribute less crisis responsibility and held an improved regard of reputation towards a corporation when they read online comments defending the corporation compared to when participants only read the news. Our findings suggest corporate communication practitioners should acknowledge the role of online comments that could motivate people to attribute crisis responsibility in a positive direction.

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