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

Neurocritical Care volume 27, pages 154–162 (2017)Cite this article

Abstract

Background

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 USA.

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 neurointensive care unit independent of whether a formal decision aid is used.

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Funding

Funded by NIH/NICHD Grant 5K23HD080971 (PI Muehlschlegel). This project was additionally supported by the University of Massachusetts Medical School Center for Clinical and Translational Science which is funded by the NIH Clinical and Translational Science Award to the University of Massachusetts Medical School (UL1TR000161).

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Authors and Affiliations

  1. Department of Neurology (Neurocritical Care), University of Massachusetts Medical School, 55 Lake Ave North, S-5, Worcester, MA, USA

    Thomas Quinn, Jesse Moskowitz, Muhammad W. Khan & Susanne Muehlschlegel

  2. Departments of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Lori Shutter

  3. Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA

    Robert Goldberg

  4. Shared Decision Making Resources, Georgetown, ME, USA

    Nananda Col

  5. Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA

    Kathleen M. Mazor

  6. Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA

    Kathleen M. Mazor

  7. Department of Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA

    Susanne Muehlschlegel

  8. Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA

    Susanne Muehlschlegel

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  1. Thomas Quinn
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  2. Jesse Moskowitz
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Correspondence to Susanne Muehlschlegel.

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Quinn, T., Moskowitz, J., Khan, M.W. et al. What Families Need and Physicians Deliver: Contrasting Communication Preferences Between Surrogate Decision-Makers and Physicians During Outcome Prognostication in Critically Ill TBI Patients. Neurocrit Care 27, 154–162 (2017). https://doi.org/10.1007/s12028-017-0427-2

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Keywords

  • Shared decision making
  • Goals-of-care decisions
  • Decision aid
  • Qualitative research
  • Traumatic brain injury
  • Critical care
  • Surrogate decision-maker