Vagueness in Goals-of-Care Conferences for Critically Ill Patients: Types of Hedge Language Used by Physicians*

Abstract

OBJECTIVES: Hedge language is a category of language that refers to words or phrases that make statements “fuzzier.” We sought to understand how physicians use hedge language during goals-of-care conferences in the ICU. DESIGN: Secondary analysis of transcripts of audio-recorded goals-of-care conferences in the ICU. SETTING: Thirteen ICUs at six academic and community medical centers in the United States. PATIENTS: Conferences were between clinicians and surrogates of incapacitated, critically ill adults. INTERVENTIONS: Four investigators performed a qualitative content analysis of transcripts using deductive followed by inductive methods to identify types of hedge language used by physicians, then coded all instances of hedge language across 40 transcripts to characterize general patterns in usage. MEASUREMENTS AND MAIN RESULTS: We identified 10 types of hedge language: numeric probabilistic statement (“there’s an 80% chance”), qualitative probabilistic statement (“there’s a good chance”), nonprobabilistic uncertainty statement (“hard to say for her”), plausibility shield (“we expect”), emotion-based statement (“we’re concerned”), attribution shield (“according to Dr. X”), adaptor (“sort of”), metaphor (“the chips are stacking up against her”), time reference (“too soon to tell”), and contingency statement (“if we are lucky”). For most types of hedge language, we identified distinct subtypes. Physicians used hedge language frequently in every transcript (median: 74 hedges per transcript) to address diagnosis, prognosis, and treatment. We observed large variation in how frequently each type and subtype of hedge language was used. CONCLUSIONS: Hedge language is ubiquitous in physician-surrogate communication during goals-of-care conferences in the ICU and can be used to introduce vagueness to statements in ways beyond expressing uncertainty. It is not known how hedge language impacts decision-making or clinician-surrogate interactions. This study prioritizes specific types of hedge language for future research based on their frequency and novelty.

The authors reply

“…W e thank Dr. Hassaballa (1) and agree that, at least some of the time, hedge language conveys genuine clinical uncertainty about prognosis, diagnosis, or treatment options. However, our analysis (2) shows that some hedges do not express clinical uncertainty.…”

“…Further studies are needed to map out the misconceptions and misunderstandings that hedge language can engender so that hedge language can be used more wisely. T his letter is in regard to an article published by Ospina-Tascon et al (1) in a recent issue of Critical Care Medicine. In a pig model of endotoxic shock, the authors noted better splanchnic blood flow, lower resuscitation fluids, and lower extravascular lung water in the immediate norepinephrine group compared with the fluid bolus group.…”

The Fuzzy Language of Critical Care Clinicians During Goals-of-Care Conversations: (Some Would Say It Is Probably) Time to Address Intentions and Consequences...*

“…In this issue of Critical Care Medicine , Mittal et al (7) assembled a multidisciplinary research team with expertise in language analysis to study hedge language. The authors defined hedge language as language that “makes statements fuzzier.” In the clinical setting, hedge language can be used by healthcare practitioners to convey clinical uncertainty (e.g., when the diagnosis or prognosis of a patient is not clear), but can also add vagueness to language used to share information that raises little doubt in the physician’s mind.…”

“…It could also result from clinicians’ knowledge gaps and clinical inexperience making them unable to adequately predict the clinical trajectory of a patient despite existing data indicative of a strong probability of a particular outcome (9); an issue that could be called “perceived” clinical uncertainty. However, the study by Mittal et al (7) indicates that hedge language is also used in the absence of clinical uncertainty (real or perceived), and must therefore be adopted for other reasons, such as being unconsciously learned from role models, as a self-preservation strategy for clinicians, or as a display of clinician’s compassion toward surrogates. Many of our learned clinical behaviors are the results of years of observation and practice, ideally informed by self-reflection and external feedback (10).…”

“…Mittal et al (7) have only scratched the surface of the clinicians’ use of language in goals-of-care conversations, and yet have raised awareness about a topic that deserves greater attention from critical care clinicians, educators, and researchers. Their work illustrates the complexity and multifaceted nature of communication in healthcare, and the importance of linguistic studies in advancing our theoretical understanding of communication during goals-of-care conversations and in informing future educational strategies.…”