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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.

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.

SUBMITTER: Quinn T

PROVIDER: S-EPMC5693603 | biostudies-literature | 2017 Oct

REPOSITORIES: biostudies-literature

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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.

Quinn Thomas T Moskowitz Jesse J Khan Muhammad W MW Shutter Lori L Goldberg Robert R Col Nananda N Mazor Kathleen M KM Muehlschlegel Susanne S

Neurocritical care 20171001 2

<h4>Background</h4>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.<h4>Methods</h4> ...[more]

PMID: 28685395

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Project description:ObjectiveThe objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes.MethodPart 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments.ResultsPart 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30).Significance of resultsPreliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Project description:ObjectiveSevere traumatic brain injury is a significant cause of morbidity and mortality in young adults. Assessing long-term neurological outcome after such injury is difficult and often characterised by uncertainty. The objective of this feasibility study was to establish the feasibility of conducting a large, multicentre prospective study to develop a prognostic model of long-term neurological outcome in critically ill patients with severe traumatic brain injury.DesignA prospective cohort study.Setting9 Canadian intensive care units enrolled patients suffering from acute severe traumatic brain injury. Clinical, biological, radiological and electrophysiological data were systematically collected during the first week in the intensive care unit. Mortality and functional outcome (Glasgow Outcome Scale extended) were assessed on hospital discharge, and then 3, 6 and 12?months following injury.OutcomesThe compliance to protocolised test procedures was the primary outcome. Secondary outcomes were enrolment rate and compliance to follow-up.ResultsWe successfully enrolled 50 patients over a 12-month period. Most patients were male (80%), with a median age of 45?years (IQR 29.0-60.0), a median Injury Severity Score of 38 (IQR 25-50) and a Glasgow Coma Scale of 6 (IQR 3-7). Mortality was 38% (19/50) and most deaths occurred following a decision to withdraw life-sustaining therapies (18/19). The main reasons for non-enrolment were the time window for inclusion being after regular working hours (35%, n=23) and oversight (24%, n=16). Compliance with protocolised test procedures ranged from 92% to 100% and enrolment rate was 43%. No patients were lost to follow-up at 6?months and 2 were at 12?months.ConclusionsIn this multicentre prospective feasibility study, we achieved feasibility objectives pertaining to compliance to test, enrolment and follow-up. We conclude that the TBI-Prognosis prospective multicentre study in severe traumatic brain injury patients in Canada is feasible.

Project description:BACKGROUND: The process of prognostication has not been described for acutely hospitalized older patients. OBJECTIVE: To investigate (1) which factors are associated with 90-day mortality risk in a group of acutely hospitalized older medical patients, and (2) whether adding a clinical impression score of nurses or physicians improves the discriminatory ability of mortality prediction. DESIGN: Prospective cohort study. PARTICIPANTS: Four hundred and sixty-three medical patients 65 years or older acutely admitted from November 1, 2002, through July 1, 2005, to a 1024-bed tertiary university teaching hospital. MEASUREMENTS: At admission, the attending nurse and physician were asked to give a clinical impression score for the illness the patient was admitted for. This score ranged from 1 (high possibility of a good outcome) until 10 (high possibility of a bad outcome, including mortality). Of all patients baseline characteristics and clinical parameters were collected. Mortality was registered up to 90 days after admission. MAIN RESULTS: In total, 23.8% (n = 110) of patients died within 90 days of admission. Four parameters were significantly associated with mortality risk: functional impairment, diagnosis malignancy, co-morbidities and high urea nitrogen serum levels. The AUC for the baseline model which included these risk factors (model 1) was 0.76 (95% CI 0.71 to 0.82). The AUC for the model using the risk factors and the clinical impression score of the physician (model 2) was 0.77 (0.71 to 0.82). The AUC for the model using the risk factors and the clinical impression score of the nurse (model 3) was 0.76 (0.71 to 0.82) and the AUC for the model, including the baseline covariates and the clinical impression score of both nurses and physicians was 0.77 (0.72 to 0.82). Adding clinical impression scores to model 1 did not significantly improve its accuracy. CONCLUSION: A set of four clinical variables predicted mortality risk in acutely hospitalized older patients quite well. Adding clinical impression scores of nurses, physicians or both did not improve the discriminating ability of the model.

Dataset Information

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

Publications

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

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