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Vagueness in Goals-of-Care Conferences for Critically Ill Patients: Types of Hedge Language Used by Physicians
Vaishali Mittal1,2, Nicholas A Hakes1,3, David Magnus1,4,5
1Center for Biomedical Ethics, Stanford University, Stanford, CA.
Insights
Physicians frequently use hedge language in intensive care unit (ICU) goals-of-care conferences, employing various types to convey information. This study identified 10 categories of hedge language, highlighting its common use in critical care communication.
Area of Science:
- Medical Communication
- Linguistics in Medicine
- Critical Care Medicine
Background:
- Hedge language, or words/phrases that introduce vagueness, is common in medical discourse.
- Understanding physician use of hedge language during goals-of-care (GOC) conferences is crucial for effective communication with surrogates.
Purpose of the Study:
- To investigate how physicians utilize hedge language in intensive care unit (ICU) goals-of-care conferences.
- To identify and categorize the types of hedge language employed by physicians in this setting.
Main Methods:
- Secondary analysis of 40 audio-recorded GOC conference transcripts from 13 ICUs.
- Qualitative content analysis using deductive and inductive methods to identify and code hedge language instances.
Main Results:
- Ten distinct types of hedge language were identified, including probabilistic statements, uncertainty statements, and attribution shields.
- Physicians frequently used hedge language in all transcripts (median: 74 instances per transcript) when discussing diagnosis, prognosis, and treatment.
- Significant variation was observed in the frequency of use for each hedge language type and subtype.
Conclusions:
- Hedge language is ubiquitous in ICU GOC conferences, serving purposes beyond merely expressing uncertainty.
- The impact of hedge language on decision-making and clinician-surrogate interactions remains unknown.
- This research identifies specific hedge language types for future investigation based on frequency and novelty.
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.
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