A Randomized Trial of Two Methods to Disclose Prognosis to Surrogate Decision Makers in Intensive Care Units

Char, Susan J. Lee; Evans, Leah R.; Malvar, Grace; White, Douglas B.

doi:10.1164/rccm.201002-0262oc

Cited by 86 publications

(35 citation statements)

References 37 publications

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“…Surrogates also considered patient attributes, including strength of character, life history, appearance and faith when estimating their loved ones’ prognoses [21]. A randomized trial of video-simulated family meetings with 169 surrogates of medical ICU patients, with prognosis conveyed numerically vs. qualitatively, revealed that neither surrogates’ personal estimates nor their understanding of the physician’s prognostication differed between the interventions [22]. This suggests that numeric estimates alone are unlikely to improve a surrogate’s understanding of prognosis, albeit validation of these findings in neuroICU patients is pending.…”

Section: Discussionmentioning

confidence: 99%

What Families Need and Physicians Deliver: Contrasting Communication Preferences Between Surrogate Decision-Makers and Physicians During Outcome Prognostication in Critically Ill TBI Patients

et al. 2017

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Introduction 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 U.S. 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 neuroICU independent of whether a formal decision aid is used.

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Section: Discussionmentioning

confidence: 99%

What Families Need and Physicians Deliver: Contrasting Communication Preferences Between Surrogate Decision-Makers and Physicians During Outcome Prognostication in Critically Ill TBI Patients

et al. 2017

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“…Two recent studies in ICUs suggest that using numeric statements to convey prognosis is not more effective than using qualitative statements, and both types of statements are frequently misunderstood (60–61). If clinicians choose to convey prognostic estimates by giving numerical risk information, clinicians should use whole numbers rather than fractions (e.g.…”

Section: Methodsmentioning

confidence: 99%

Shared Decision Making in ICUs

Kon

Davidson

Morrison

et al. 2016

Critical Care Medicine

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396

134

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Objectives Shared decision-making (SDM) is endorsed by critical care organizations, however there remains confusion about what SDM is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define SDM, recommend when SDM should be used, identify the range of ethically acceptable decision-making models, and present important communication skills. Methods The American College of Critical Care Medicine (ACCM) and American Thoracic Society (ATS) Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of ACCM and ATS were included in the statement. Main Results Six recommendations were endorsed: 1) Definition: Shared decision-making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals, and preferences. 2) Clinicians should engage in a SDM process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their “default” approach a SDM process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies. Conclusions Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.

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“…This is suggested by studies demonstrating that surrogates’ prognostic estimates are often discordant with physicians’, even when communication is rated highly (11–14). Poor numeracy (ability to understand and apply numeric information) may impair the ability of surrogates to understand and interpret the data provided (15, 16), with lower numeracy resulting in more discordance (11).…”

Section: Introductionmentioning

confidence: 99%

Numeracy and Interpretation of Prognostic Estimates in Intracerebral Hemorrhage Among Surrogate Decision Makers in the Neurologic ICU

Leiter

Motta

Reed

et al. 2018

Critical Care Medicine

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OBJECTIVE Clinicians caring for patients with intracerebral hemorrhage (ICH) must often discuss prognosis and goals of care with their patients’ surrogate decision makers, and may make numeric estimates of likelihood of survival and functional independence, informed by validated prediction models. Surrogates’ prognostic estimates are often discordant with physicians’, suggesting that physicians’ numeric statements may not be accurately interpreted. We sought to assess the relationship between numeracy and interpretation of prognostic estimates in ICH among surrogate decision makers. We also assessed surrogates’ application of prognostic estimates to decisions regarding goals of care. DESIGN Single-center, survey-based, cross-sectional study SETTING 22-bed neurologic intensive care unit (ICU) at an urban, academic hospital SUBJECTS Surrogate decision makers for patients admitted to the neurologic ICU INTERVENTIONS Participants completed a survey containing 5 clinical vignettes describing patients with non-traumatic ICH. For each patient, numerical estimates of survival and functional independence were explicitly provided, based on the validated ICH score, and the Prediction of Functional Outcome in Patients with Primary Intracerebral Hemorrhage (FUNC) score. MEASUREMENTS AND MAIN RESULTS Participants were asked to make their own prognostic estimates, as well as to describe their preferred goals of care for each hypothetical patient. Respondent demographics were collected, and numeracy was assessed using a modified Lipkus 11-item scale. Poor numeracy was common (42 out of 96 subjects) in this relatively highly educated population. Most prognostic estimates (55%) made by surrogates were discordant with the provided estimates. High numeracy correlated with better concordance (OR 23.9 [5.57–97.64], p<0.001), independent of several factors, including level of education and religion. Numeracy also affected goals-of-care decisions made by surrogates. CONCLUSIONS Poor numeracy, resulting in impaired understanding of statistics and risk magnitudes, is common among surrogate decision makers in an intensive care setting, and poses a barrier to communication between surrogates and clinicians regarding prognosis and goals of care.

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A Randomized Trial of Two Methods to Disclose Prognosis to Surrogate Decision Makers in Intensive Care Units

Cited by 86 publications

References 37 publications

What Families Need and Physicians Deliver: Contrasting Communication Preferences Between Surrogate Decision-Makers and Physicians During Outcome Prognostication in Critically Ill TBI Patients

What Families Need and Physicians Deliver: Contrasting Communication Preferences Between Surrogate Decision-Makers and Physicians During Outcome Prognostication in Critically Ill TBI Patients

Shared Decision Making in ICUs

Numeracy and Interpretation of Prognostic Estimates in Intracerebral Hemorrhage Among Surrogate Decision Makers in the Neurologic ICU

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