Goal-Concordant Care After Severe Acute Brain Injury

Voumard, Rachel Rutz; Dugger, Kaley M; Kiker, Whitney A; Barber, Jason; Borasio, Gian Domenico; Curtis, J. Randall; Jox, Ralf J.; Creutzfeldt, Claire J.

doi:10.3389/fneur.2021.710783

Cited by 10 publications

(17 citation statements)

References 22 publications

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“…Although no score will replace the clinician’s expertise and clinical assessment for a given patient, predictive scores could help navigate this uncertainty. Clinicians’ reluctance to use scores has already been described [ 12 , 36 , 37 ]; nevertheless, many prognostic scores have been shown to be more accurate than clinical judgement, even for experienced clinicians [ 9 ]. Clinicians’ estimate of terminally ill patients’ survival is also known to be inaccurate and most often overestimated, which impacts LST decisions [ 38 ].…”

Section: Discussionmentioning

confidence: 99%

“…When patients lack decision-making capacity, their surrogate decision makers are called upon to make decisions on their behalves. While most patients prefer their family members to act as surrogate decision makers, [ 9 ], family members often feel unprepared for making LST decisions in acute situations given the uncertainty and the moral burden of such decisions [ 10 , 11 , 12 ]. Several strategies have been suggested to better support families facing LST decisions, but the effect of these interventions on psychological distress has been limited [ 13 , 14 , 15 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

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‘We Have Guidelines, but We Can Also Be Artists’: Neurologists Discuss Prognostic Uncertainty, Cognitive Biases, and Scoring Tools

et al. 2022

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Introduction: Ischemic stroke is a leading cause of disability and mortality worldwide. As acute stroke patients often lose decision-making capacity, acute management is fraught with complicated decisions regarding life-sustaining treatment (LST). We aimed to explore (1) the perspectives and experiences of clinicians regarding the use of predictive scores for LST decision making in severe acute stroke, and (2) clinicians’ awareness of their own cognitive biases in this context. Methods: Four focus groups (FGs) were conducted with 21 physicians (13 residents and 8 attending physicians); two FGs in a university hospital and two in a regional hospital in French-speaking Switzerland. Discussions were audio-recorded and transcribed verbatim. Transcripts were analyzed thematically. Two of the four transcripts were double coded to establish coding framework consistency. Results: Participants reported that predictive tools were not routinely used after severe stroke, although most knew about such scores. Scores were reported as being useful in quantifying prognosis, advancing scientific evidence, and minimizing potential biases in decisions. Their use is, however, limited by the following barriers: perception of inaccuracy, general disbelief in scoring, fear of self-fulfilling prophecy, and preference for clinical judgement. Emotional and cognitive biases were common. Emotional biases distort clinicians’ knowledge and are notably: bias of personal values, negative experience, and cultural bias. Cognitive biases, such as availability, confirmation, and anchoring biases, that produce systematic deviations from rational thinking, were also identified. Conclusions: The results highlight opportunities to improve decision making in severe stroke through the promotion of predictive tools, strategies for communicating prognostic uncertainty, and minimizing cognitive biases among clinicians, in order to promote goal-concordant care.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

‘We Have Guidelines, but We Can Also Be Artists’: Neurologists Discuss Prognostic Uncertainty, Cognitive Biases, and Scoring Tools

et al. 2022

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“…7 However, recent studies demonstrated that over 70% of patients with acute brain injury and family members' who perceived comfortoriented care as the prioritized therapeutic goal received goal-discordant care. 1 The need for rapid decision-making complicates discussions regarding acute therapies for neurologic emergencies and MOLST reversal. For example, thrombectomy for ischemic stroke requires rapid treatment decisions and has diminishing returns on outcomes with passing time.…”

Section: Discussionmentioning

confidence: 99%

“…7 However, recent studies demonstrated that over 70% of patients with acute brain injury and family members’ who perceived comfort-oriented care as the prioritized therapeutic goal received goal-discordant care. 1…”

Section: Discussionmentioning

confidence: 99%

“…Goal concordant care is medical care that honors a patient's individual goals and values, and subsequent alignment of medical treatments with those goals. 1 Up to 38% of patients admitted to intensive care units received higher intensity care than what was documented in their pre-existing MOLST, most commonly in the setting of acute trauma. 2 MOLST (or Physician Orders for Life-Sustaining Treatment, among other terms depending on practice location), however, is not necessarily a reliable surrogate for patient value-oriented care or goal concordance.…”

Section: Introductionmentioning

confidence: 99%

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Reversal of Advanced Directives in Neurologic Emergencies

McHugh

George

Bender

et al. 2022

The Neurohospitalist

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Objective Patients with advanced directives or Medical Orders for Life-Sustaining Treatment (MOLST), including “Do Not Resuscitate” (DNR) and/or “Do Not Intubate” (DNI), may be candidates for procedural interventions when presenting with acute neurologic emergencies. Such interventions may limit morbidity and mortality, but typically they require MOLST reversal. We investigated outcomes of patients with MOLST reversal for treatment of neurologic emergencies. Methods We conducted a retrospective chart review from July 1, 2019 to April 30, 2021 of patients with MOLST reversal treated in our NeuroMedicine Intensive Care Unit. Variables collected include neurologic disease, MOLST reversal decision maker, procedural interventions, and outcomes. Results Twenty-seven patients (18 female, median age 78 years (IQR 73-85 years), median baseline modified Rankin score 1 [IQR 0-2.5] were identified with MOLST reversal. The most common pre-procedural MOLST was DNR/DNI (n=22, 81%), and 93% (n=25) pre-procedural MOLSTs were completed by the patient. MOLSTs were reversed by surrogates in n=23 cases (85%). The median time from MOLST completion to MOLST reversal was 603 days (IQR 45 days to 4 years). The most common neurologic emergency was ischemic stroke (n=14, 52%). Most patients died (n=14, 52%), 26% (n=7) were discharged to skilled nursing, and 22% (n=6) returned to home or assisted living. Conclusions In neurologic emergencies, urgent shared decision making is needed to ensure goal-concordant care, which may result in reversal of existing advanced directives. Outcomes of patients with MOLST reversal were heterogeneous, emphasizing the importance of deliberate patient-centered care weighing the risks and benefits of each intervention.

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Identification of Palliative Care Needs and Mental Health Outcomes Among Family Members of Patients With Severe Acute Brain Injury

et al. 2023

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ImportanceFamily members of patients with severe acute brain injury (SABI) are at risk for poor psychological outcomes.ObjectiveTo explore the utility of the early use of a palliative care needs checklist in identifying care needs of patients with SABI and family members who are at risk of poor psychological outcomes.Design, Setting, and ParticipantsThis prospective cohort study included patients with SABI in an intensive care unit (ICU) for 2 days or more and a Glasgow Coma Scale score of 12 or lower and their family members. This single-center study was conducted at an academic hospital in Seattle, Washington, from January 2018 to June 2021. Data were analyzed from July 2021 to July 2022.ExposureAt enrollment, a 4-item palliative care needs checklist was completed separately by clinicians and family members.Main Outcomes and MeasuresA single family member for each enrolled patient completed questionnaires assessing symptoms of depression and anxiety, perception of goal-concordant care, and satisfaction in the ICU. Six months later, family members assessed their psychological symptoms, decisional regret, patient functional outcome, and patient quality of life (QOL).ResultsA total of 209 patient–family member pairs (family member mean [SD] age, 51 [16] years; 133 women [64%]; 18 Asian [9%], 21 Black [10%], 20 [10%] Hispanic, and 153 White [73%] participants) were included. Patients had experienced stroke (126 [60%]), traumatic brain injury (62 [30%]), and hypoxic-ischemic encephalopathy (21 [10%]). At least 1 need was identified for 185 patients or their families (88%) by family members and 110 (53%) by clinicians (κ = −0.007; 52% agreement). Symptoms of at least moderate anxiety or depression were present in 50% of family members at enrollment (87 with anxiety and 94 with depression) and 20% at follow-up (33 with anxiety and 29 with depression). After adjustment for patient age, diagnosis, and disease severity and family race and ethnicity, clinician identification of any need was associated with greater goal discordance (203 participants; relative risk = 1.7 [95% CI, 1.2 to 2.5]) and family decisional regret (144 participants; difference in means, 17 [95% CI, 5 to 29] points). Family member identification of any need was associated with greater symptoms of depression at follow-up (150 participants; difference in means of Patient Health Questionnaire–2, 0.8 [95% CI, 0.2 to 1.3] points) and worse perceived patient QOL (78 participants; difference in means, −17.1 [95% CI, −33.6 to −0.5] points).Conclusions and RelevanceIn this prospective cohort study of patients with SABI and their families, palliative care needs were common, although agreement on needs was poor between clinicians and family members. A palliative care needs checklist completed by clinicians and family members may improve communication and promote timely, targeted management of needs.

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Goal-Concordant Care After Severe Acute Brain Injury

Cited by 10 publications

References 22 publications

‘We Have Guidelines, but We Can Also Be Artists’: Neurologists Discuss Prognostic Uncertainty, Cognitive Biases, and Scoring Tools

‘We Have Guidelines, but We Can Also Be Artists’: Neurologists Discuss Prognostic Uncertainty, Cognitive Biases, and Scoring Tools

Reversal of Advanced Directives in Neurologic Emergencies

Identification of Palliative Care Needs and Mental Health Outcomes Among Family Members of Patients With Severe Acute Brain Injury

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