Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods...

Area of Science:

• Critical Care Medicine
• Neurology
• Medical Ethics

Background:

• Withdrawal-of-life-sustaining treatments (WOLST) rates vary significantly in critically ill neurologic patients (CINPs).
• Clinician communication of prognosis to families is highly variable and poorly understood in CINPs.
• Existing research in general critical care highlights variability in clinician prognostication.

Purpose of the Study:

• To assess the feasibility of audio-recording clinician-family meetings for CINPs across multiple centers.
• To characterize the different approaches clinicians use to communicate prognosis to families of CINPs.
• To explore associations between prognostication approaches, patient/clinician factors, and WOLST decisions.

Main Methods:

• Audio-recording of 43 clinician-family meetings involving 39 CINPs across seven U.S. centers.
• Qualitative coding of meeting transcripts by two investigators to identify prognostication approaches (Authoritative, Informational, Advisory, Responsive).
• Application of logistic regression to analyze associations between prognostication, patient/clinician characteristics, and WOLST.

Main Results:

• Four prognostication approaches were identified: Authoritative (21%), Informational (23%), Advisory (42%), and Responsive (14%).
• Clinician specialty independently predicted prognostication approach after adjustment.
• Withdrawal-of-life-sustaining treatments (WOLST) occurred in 41% of patients, most frequently under the advisory approach (56%), but prognostication approach was not independently associated with WOLST.

Conclusions:

• Audio-recording clinician-family meetings in ICUs for CINPs is feasible.
• Clinicians demonstrate significant variability in how they communicate prognosis.
• Further research is needed to understand the impact of variable prognostication on WOLST decisions in CINPs.