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Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units

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Abstract

In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.

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Acknowledgments

Liana Fraenkel receives research support from the NIH 5K24AR060231-02, 5P60AR047782, and the VA Health Services Research IIR. David Y. Hwang has received an American Brain Foundation Practice Research Training Fellowship. Douglas B. White receives research support from NIH 1R01AG045176-01 and 1R01NR014663.

Conflict of interest

Xuemei Cai, Jennifer Robinson, Susanne Muehlschlegel, Kevin N. Sheth, and Robert G. Holloway declare that they have no conflicts of interest. Douglas B. White has no relevant conflicts of interest.

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Authors and Affiliations

  1. Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA

    Xuemei Cai

  2. Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA

    Jennifer Robinson, Kevin N. Sheth & David Y. Hwang

  3. Departments of Neurology, Anesthesia/Critical Care, and Surgery, University of Massachusetts Medical School, Worcester, MA, USA

    Susanne Muehlschlegel

  4. Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Douglas B. White

  5. Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA

    Robert G. Holloway

  6. Division of Rheumatology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA

    Liana Fraenkel

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  1. Xuemei Cai
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  2. Jennifer Robinson
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Correspondence to Xuemei Cai.

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Cai, X., Robinson, J., Muehlschlegel, S. et al. Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units. Neurocrit Care 23, 131–141 (2015). https://doi.org/10.1007/s12028-015-0149-2

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