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Keuper K, England AE, Shah RC, Quinn TV, Gerhart J, Greenberg JA. Surrogate and Physician Decision Making for Mechanically Ventilated Patients According to Expected Patient Outcome. J Palliat Med 2021; 25:907-914. [PMID: 34964669 DOI: 10.1089/jpm.2021.0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Surrogates and physicians may differ in their priorities and perspectives when making decisions for incapacitated, critically ill patients. Objectives: To determine the extent to which surrogate and physician decisions to sustain life support are associated with their expectations for patient outcomes. Setting/Subjects: Surrogates and physicians of 100 mechanically ventilated patients at an academic, tertiary care medical center in the United States were surveyed. Measurements: Linear regression was used to determine if participant expectations for patient survival, good quality of life, and confidence in these expectations were associated with their agreement that mechanical ventilation should be continued if required for patient survival. Results: Surrogates were more likely than physicians to expect that patients would be alive in three months (91% interquartile range [IQR 70-95%] vs. 65% [IQR 43-77%], p < 0.001) and have good quality of life in three months (71% [IQR 50-90%] vs. 40% [IQR 19-50%], p < 0.001). Surrogates who were most confident in their prognostic abilities were also the most optimistic for good patient outcomes. As such, expectations for patient survival and good quality of life were not associated with level agreement that mechanical ventilation should be continued among confident surrogates, (R2 = 0.03, p = 0.13) and (R2 = 0.01, p = 0.53), respectively. In contrast, among physicians, confidence was not synonymous with optimism. Instead, the significant associations between expectations for patient survival and good quality of life with the agreement that mechanical ventilation should be continued were strengthened when physicians were confident, (R2 = 0.34, p < 0.01) and (R2 = 0.47, p < 0.001), respectively. Conclusion: Surrogates and physicians have different approaches to incorporating their expectations for patient prognosis and their confidence in these expectations when they are making decisions for incapacitated critically ill patients.
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Affiliation(s)
- Kevin Keuper
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Ashley Eaton England
- Department of Psychology, Central Michigan University, Mount Pleasant, Michigan, USA
| | - Raj C Shah
- Department of Family Medicine and the Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Thomas V Quinn
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - James Gerhart
- Department of Psychology, Central Michigan University, Mount Pleasant, Michigan, USA.,Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Jared A Greenberg
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Goostrey KJ, Lee C, Jones K, Quinn T, Moskowitz J, Pach JJ, Knies AK, Shutter L, Goldberg R, Mazor KM, Hwang DY, Muehlschlegel S. Adapting a Traumatic Brain Injury Goals-of-Care Decision Aid for Critically Ill Patients to Intracerebral Hemorrhage and Hemispheric Acute Ischemic Stroke. Crit Care Explor 2021; 3:e0357. [PMID: 33786434 PMCID: PMC7994105 DOI: 10.1097/cce.0000000000000357] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Families in the neurologic ICU urgently request goals-of-care decision support and shared decision-making tools. We recently developed a goals-of-care decision aid for surrogates of critically ill traumatic brain injury patients using a systematic development process adherent to the International Patient Decision Aid Standards. To widen its applicability, we adapted this decision aid to critically ill patients with intracerebral hemorrhage and large hemispheric acute ischemic stroke. DESIGN Prospective observational study. SETTING Two academic neurologic ICUs. SUBJECTS Twenty family members of patients in the neurologic ICU were recruited from July 2018 to October 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We reviewed the existing critically ill traumatic brain injury patients decision aid for content and changed: 1) the essential background information, 2) disease-specific terminology to "hemorrhagic stroke" and "ischemic stroke", and 3) disease-specific prognosis tailored to individual patients. We conducted acceptability and usability testing using validated scales. All three decision aids contain information from validated, disease-specific outcome prediction models, as recommended by international decision aid standards, including careful emphasis on their uncertainty. We replaced the individualizable icon arrays graphically depicting probabilities of a traumatic brain injury patient's prognosis with icon arrays visualizing intracerebral hemorrhage and hemispheric acute ischemic stroke prognostic probabilities using high-quality disease-specific data. We selected the Intracerebral Hemorrhage Score with validated 12-month outcomes, and for hemispheric acute ischemic stroke, the 12-month outcomes from landmark hemicraniectomy trials. Twenty family members participated in acceptability and usability testing (n = 11 for the intracerebral hemorrhage decision aid; n = 9 for the acute ischemic stroke decision aid). Median usage time was 22 minutes (interquartile range, 16-26 min). Usability was excellent (median System Usability Scale = 84/100 [interquartile range, 61-93; with > 68 indicating good usability]); 89% of participants graded the decision aid content as good or excellent, and greater than or equal to 90% rated it favorably for information amount, balance, and comprehensibility. CONCLUSIONS We successfully adapted goals-of-care decision aids for use in surrogates of critically ill patients with intracerebral hemorrhage and hemispheric acute ischemic stroke and found excellent usability and acceptability. A feasibility trial using these decision aids is currently ongoing to further validate their acceptability and test their feasibility for use in busy neurologic ICUs.
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Affiliation(s)
- Kelsey J. Goostrey
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA
| | - Christopher Lee
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA
| | - Kelsey Jones
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA
| | - Thomas Quinn
- Department of Medicine, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA
| | - Jesse Moskowitz
- Department of Psychiatry, Brown Medical School, Providence, RI
| | - Jolanta J. Pach
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Andrea K. Knies
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Lori Shutter
- Departments of Critical Care Medicine and Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Kathleen M. Mazor
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA
- Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA
| | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT
- Center for Neuroepidemiology and Clinical Neurological Research, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA
- Department of Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA
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Chen EP, Arslanian-Engoren C, Newhouse W, Egleston D, Sahgal S, Yande A, Fagerlin A, Zahuranec DB. Development and usability testing of Understanding Stroke, a tailored life-sustaining treatment decision support tool for stroke surrogate decision makers. BMC Palliat Care 2020; 19:110. [PMID: 32689982 PMCID: PMC7370629 DOI: 10.1186/s12904-020-00617-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Surrogate decision makers of stroke patients are often unprepared to make critical decisions on life-sustaining treatments. We describe the development process and key features for the Understanding Stroke web-based decision support tool. METHODS We used multiple strategies to develop a patient-centered, tailored decision aid. We began by forming a Patient and Family Advisory Council to provide continuous input to our multidisciplinary team on the development of the tool. Additionally, focus groups consisting of nurses, therapists, social workers, physicians, stroke survivors, and family members reviewed key elements of the tool, including prognostic information, graphical displays, and values clarification exercise. To design the values clarification exercise, we asked focus groups to provide feedback on a list of important activities of daily living. An ordinal prognostic model was developed for ischemic stroke and intracerebral hemorrhage using data taken from the Virtual International Stroke Trials Archive Plus, and incorporated into the tool. RESULTS Focus group participants recommended making numeric prognostic information optional due to possible emotional distress. Pie charts were generally favored by participants for graphical presentation of prognostic information, though a horizontal stacked bar chart was also added due to its prevalence in stroke literature. Plain language descriptions of the modified Rankin Scale were created to accompany the prognostic information. A values clarification exercise was developed consisting of a list of 13 situations that may make an individual consider comfort measures only. The final version of the web based tool (which can be viewed on tablets) included the following sections: general introduction to stroke, outcomes (prognostic information and recovery), in-hospital and life-sustaining treatments, decision making and values clarification, post-hospital care, tips for talking to the health care team, and a summary report. Preliminary usability testing received generally favorable feedback. CONCLUSION We developed Understanding Stroke, a tailored decision support tool for surrogate decision makers of stroke patients. The tool was well received and will be formally pilot tested in a group of stroke surrogate decision makers. TRIAL REGISTRATION ClinicalTrials.gov ( NCT03427645 ).
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Affiliation(s)
- Emily P Chen
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, USA
| | - Cynthia Arslanian-Engoren
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, USA
| | - William Newhouse
- Center for Health Communications Research, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, USA
| | - Diane Egleston
- Center for Health Communications Research, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, USA
| | | | | | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, USA
| | - Darin B Zahuranec
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, USA.
- Department of Neurology, University of Michigan Medical School, Ann Arbor, USA.
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Muehlschlegel S, Hwang DY, Flahive J, Quinn T, Lee C, Moskowitz J, Goostrey K, Jones K, Pach JJ, Knies AK, Shutter L, Goldberg R, Mazor KM. Goals-of-care decision aid for critically ill patients with TBI: Development and feasibility testing. Neurology 2020; 95:e179-e193. [PMID: 32554766 DOI: 10.1212/wnl.0000000000009770] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 12/17/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To develop and demonstrate early feasibility of a goals-of-care decision aid for surrogates of patients who are critically ill with traumatic brain injury (ciTBI) that meets accepted international decision aid guidelines. METHODS We developed the decision aid in 4 stages: (1) qualitative study of goals-of-care communication and decision needs of 36 stakeholders of ciTBI (surrogates and physicians), which informed (2) development of paper-based decision aid with iterative revisions after feedback from 52 stakeholders; (3) acceptability and usability testing in 18 neurologic intensive care unit (neuroICU) family members recruited from 2 neuroICU waiting rooms using validated scales; and (4) open-label, randomized controlled feasibility trial in surrogates of ciTBI. We performed an interim analysis of 16 surrogates of 12 consecutive patients who are ciTBI to confirm early feasibility of the study protocol and report recruitment, participation, and retention rates to date. RESULTS The resultant goals-of-care decision aid achieved excellent usability (median System Usability Scale 87.5 [possible range 0-100]) and acceptability (97% graded the tool's content as "good" or "excellent"). Early feasibility of the decision aid and the feasibility trial protocol was demonstrated by high rates of recruitment (73% consented), participation (100%), and retention (100% both after the goals-of-care clinician-family meeting and at 3 months) and complete data for the measurements of all secondary decision-related and behavioral outcomes to date. CONCLUSIONS Our systematic development process resulted in a novel goals-of-care decision aid for surrogates of patients who are ciTBI with excellent usability, acceptability, and early feasibility in the neuroICU environment, and meets international decision aid standards. This methodology may be a development model for other decision aids in neurology to promote shared decision-making.
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Affiliation(s)
- Susanne Muehlschlegel
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA.
| | - David Y Hwang
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Julie Flahive
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Thomas Quinn
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Christopher Lee
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Jesse Moskowitz
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Kelsey Goostrey
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Kelsey Jones
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Jolanta J Pach
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Andrea K Knies
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Lori Shutter
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Robert Goldberg
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Kathleen M Mazor
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
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Hwang DY, Knies AK, Mampre D, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L. Concerns of surrogate decision makers for patients with acute brain injury: A US population survey. Neurology 2020; 94:e2054-e2068. [PMID: 32341190 PMCID: PMC7282883 DOI: 10.1212/wnl.0000000000009406] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 12/03/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether groups of surrogates for patients with severe acute brain injury (SABI) with poor prognosis can be identified based on their prioritization of goals-of-care (GOC) decisional concerns, an online survey of 1,588 adults recruited via a probability-based panel representative of the US population was conducted. METHODS Participants acted as a surrogate for a GOC decision for a hypothetical patient with SABI and were randomized to 1 of 2 prognostic scenarios: the patient likely being left with a range of severe functional disability (SD) or remaining in a vegetative state (VS). Participants prioritized a list of 12 decisional concerns via best-worst scaling. Latent class analysis (LCA) was used to discover decisional groups. RESULTS The completion rate was 44.6%; data weighting was conducted to mitigate nonresponse bias. For 792 SD respondents, LCA revealed 4 groups. All groups shared concerns regarding respecting patient wishes and minimizing suffering. The 4 groups were otherwise distinguished by unique concerns that their members highlighted: an older adult remaining severely disabled (34.4%), family consensus (26.4%), doubt regarding prognostic accuracy (20.7%), and cost of long-term care (18.6%). For the 796 VS respondents, LCA revealed 5 groups. Four of the 5 groups had similar concern profiles to the 4 SD groups. The largest (29.0%) expressed the most prognostic doubt. An additional group (15.8%) prioritized religious concerns. CONCLUSIONS Although surrogate decision makers for patients with SABI are concerned with respecting patient wishes and minimizing suffering, certain groups highly prioritize other specific decisional factors. These data can help inform future interventions for supporting decision makers.
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Affiliation(s)
- David Y Hwang
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT.
| | - Andrea K Knies
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - David Mampre
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Stanislav Kolenikov
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Marci Schalk
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Heather Hammer
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Douglas B White
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Robert G Holloway
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Kevin N Sheth
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Liana Fraenkel
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
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