Effect of Intensivist Communication in a Simulated Setting on Interpretation of Prognosis Among Family Members of Patients at High Risk of Intensive Care Unit Admission

Abstract

IMPORTANCE Discordance about prognosis between a patient's health care decision-making surrogate and the treating intensivist is common in the intensive care unit (ICU). Empowering families, friends, and caregivers of patients who are critically ill to make informed decisions about care is important, but it is unclear how best to communicate prognostic information to surrogates when a patient is expected to die. OBJECTIVETo determine whether family members, who are often health care decision-making surrogates, interpret intensivists as being more optimistic when questions about prognosis in the ICU are answered indirectly. DESIGN, SETTING, AND PARTICIPANTSThis web-based randomized trial was conducted between September 27, 2019, and October 17, 2019, among a national sample of adult children, spouses, partners, or siblings of people with chronic obstructive pulmonary disease who were receiving longterm oxygen therapy. Participants were shown video vignettes depicting an intensivist answering a standardized question about the prognosis of a patient at high risk of death on day 3 of ICU admission. Participants were excluded if they had worked as a physician, nurse, or advanced health care practitioner. Data were analyzed from INTERVENTIONS Participants were randomized to view 1 of 4 intensivist communication styles in response to the question "What do you think is most likely to happen?": (1) a direct response (control), (2) an indirect response comparing the patient's condition with that of other patients, (3) an indirect response describing the patient's deteriorating physiological condition, or (4) redirection to a discussion of the patient's values and goals. MAIN OUTCOMES AND MEASURES Participant responses to 2 questions: (1) "If you had to guess,what do you think the doctor thinks is the chance that your loved one will survive this hospitalization?" and (2) "What do you think are the chances that your loved one will survive this hospitalization?" answered using a 0% to 100% probability scale. RESULTSAmong 302 participants (median [interquartile range] age, 49 [38-59] years; 204 [68%]women) included in the trial, 165 (55%) were adult children of the individual with chronic obstructive pulmonary disease; 77 participants were randomized to view a direct response, 77 participants were randomized to view an indirect response referencing other patients, 68 participants were randomized to view an indirect response referencing physiological condition, and 80 participants were randomized to view a redirection response. Compared with participants who viewed a direct response, participants who viewed an indirect response referencing other patients (β = 10 [95% CI, (continued) Key Points Question Do intensivist communication patterns affect the way family members understand their loved one's prognosis in the intensive care unit?Abstract (continued) 1-19]; P = .03), physiological condition (β = 10 [95% CI, 0-19]; P = .04), or redirection to a discussion of the patient's values and goals (β = 19 [95% CI, 10-28]; P < .001) p...

Assessment of Discordance Between Physicians and Family Members Regarding Prognosis in Patients With Severe Acute Brain Injury

“…For example, physicians often fail to ensure family understanding, they rarely use numbers to convey prognosis, 20 and families may interpret indirect comments as optimism. 21 Mitigating such pitfalls might reduce prognosis discordance. Optimistic belief difference, on the other hand, represents an intentional decision by a family member to believe a different prognosis than what the physician may have communicated.…”

Communication with relatives on prognosis of critically ill patients

“…One study showed that more than 50% of time was spent to explain prognosis. 3 The language used to discuss prognosis in ICU is variable, 4 using direct or indirect statements, 5 with quantitative or qualitative estimations (Table 1). For example, for a patient with a high probability of death, some physicians will use direct assessments focusing on the individual patient.…”

“…19 A recent study suggests that it is preferable to use direct assessments rather than indirect assessments which are perceived more optimistically by family members. 5 Finally, it is recommended that physicians check whether relatives have understood the information provided on the patient's prognosis. 1,20…”

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“…Recently, the importance of communication skills training for critical care clinicians has been attracting attention. Oppenheim et al reported that in a simulated conversation between an ICU health care provider and a patient's family regarding the patient's prognosis, family members interpret physicians’ indirect response to questions about prognosis as more optimistic than direct responses [ 41 ]. Therefore, it is important for critical care clinicians to clearly communicate the prognosis in conversations with the patient's family and then set goals of care that are aligning with the patient's values, including the initiation of palliative care.…”