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Lank RJ, Morgenstern LB, Ortiz C, Case E, Zahuranec DB. Barriers to Surrogate Application of Patient Values in Medical Decisions in Acute Stroke: Qualitative Study in a Biethnic Community. Neurocrit Care 2024; 40:215-224. [PMID: 37131090 PMCID: PMC10620105 DOI: 10.1007/s12028-023-01724-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/27/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND The objective of this study was to identify barriers to surrogate decision-maker application of patient values on life-sustaining treatments after stroke in Mexican American (MA) and non-Hispanic White (NHW) patients. METHODS We conducted a qualitative analysis of semistructured interviews with stroke patient surrogate decision-makers completed approximately 6 months after hospitalization. RESULTS Forty-two family surrogate decision-makers participated (median age: 54.5 years; female: 83%; patients were MA [60%] and NHW [36%], and 50% were deceased at the time of the interview). We identified three primary barriers to surrogates' applications of patient values and preferences when making decisions on life-sustaining treatments: (1) a minority of surrogates had no prior discussion of what the patient would want in the event of a serious medical illness, (2) surrogates struggled to apply prior known values and preferences to the actual decisions made, and (3) surrogates felt guilt or burden, often even in the setting of some knowledge of patient values or preferences. The first two barriers were seen to a similar degree in MA and NHW participants, though guilt or burden was reported more commonly among MA (28%) than NHW (13%) participants. Maintaining patient independence (e.g., ability to live at home, avoid a nursing home, make their own decisions) was the most important priority for decision-making for both MA and NHW participants; however, MA participants were more likely to list spending time with family as an important priority (24% vs. 7%). CONCLUSIONS Stroke surrogate decision-makers may benefit from (1) continued efforts to make advance care planning more common and more relevant, (2) assistance in how to apply their knowledge of patient values to actual treatment decisions, and (3) psychosocial support to reduce emotional burden. Barriers to surrogate application of patient values were generally similar in MA and NHW participants, though the possibility of greater guilt or burden among MA surrogates warrants further investigation and confirmation.
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Affiliation(s)
- Rebecca J Lank
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Lewis B Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, School of Public Health, University of Michigan, Cardiovascular Center Rm 3392 1500 E Medical Center Dr., Ann Arbor, MI, USA
| | - Carmen Ortiz
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
| | - Erin Case
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, School of Public Health, University of Michigan, Cardiovascular Center Rm 3392 1500 E Medical Center Dr., Ann Arbor, MI, USA
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Shakil H, Malhotra AK, Jaffe RH, Smith CW, Harrington EM, Wang AP, Yuan EY, He Y, Ladha K, Wijeysundera DN, Nathens AB, Wilson JR, Witiw CD. Factors influencing withdrawal of life-supporting treatment in cervical spinal cord injury: a large multicenter observational cohort study. Crit Care 2023; 27:448. [PMID: 37980485 PMCID: PMC10656773 DOI: 10.1186/s13054-023-04725-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/08/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) leads to profound neurologic sequelae, and the provision of life-supporting treatment serves great importance among this patient population. The decision for withdrawal of life-supporting treatment (WLST) in complete traumatic SCI is complex with the lack of guidelines and limited understanding of practice patterns. We aimed to evaluate the individual and contextual factors associated with the decision for WLST and assess between-center differences in practice patterns across North American trauma centers for patients with complete cervical SCI. METHODS This retrospective multicenter observational cohort study utilized data derived from the American College of Surgeons Trauma Quality Improvement Program database between 2017 and 2020. The study included adult patients (> 16 years) with complete cervical SCI. We constructed a multilevel mixed effect logistic regression model to adjust for patient, injury and hospital factors influencing WLST. Factors associated with WLST were estimated through odds ratios with 95% confidence intervals. Hospital variability was characterized using the median odds ratio. Unexplained residual variability was assessed through the proportional change in variation between models. RESULTS We identified 5070 patients with complete cervical SCI treated across 477 hospitals, of which 960 (18.9%) had WLST. Patient-level factors associated with significantly increased likelihood of WLST were advanced age, male sex, white race, prior dementia, low presenting Glasgow Coma Scale score, having a pre-hospital cardiac arrest, SCI level of C3 or above, and concurrent severe injury to the head or thorax. Patient-level factors associated with significantly decreased likelihood of WLST included being racially Black or Asian. There was significant variability across hospitals in the likelihood for WLST while accounting for case-mix, hospital size, and teaching status (MOR 1.51 95% CI 1.22-1.75). CONCLUSIONS A notable proportion of patients with complete cervical SCI undergo WLST during their in-hospital admission. We have highlighted several factors associated with this decision and identified considerable variability between hospitals. Further work to standardize WLST guidelines may improve equity of care provided to this patient population.
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Affiliation(s)
- Husain Shakil
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Armaan K Malhotra
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Rachael H Jaffe
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Christopher W Smith
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Erin M Harrington
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Alick P Wang
- Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Eva Y Yuan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Yingshi He
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Karim Ladha
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Avery B Nathens
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Trauma Surgery, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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Goss A, Ge C, Crawford S, Goostrey K, Buddadhumaruk P, Hough CL, Lo B, Carson S, Steingrub J, White DB, Muehlschlegel S. Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study. Neurology 2023; 101:e558-e569. [PMID: 37290972 PMCID: PMC10401677 DOI: 10.1212/wnl.0000000000207462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/13/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition). METHODS We conducted a multicenter cross-sectional mixed-methods study analyzing deidentified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from 7 US centers. Two coders assigned codes for prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., "80% survival"; "She'll probably survive") or nonprobabilistic (characterizing outcomes without offering likelihood; e.g., "She may not survive"). We applied univariate and multivariate binomial logistic regression to examine independent associations between prognostic language and domain of prognosis. RESULTS We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [interquartile range (IQR) 0-2]), physical function (median 2 [IQR 0-7]), cognition (median 2 [IQR 0-6]), and overall recovery (median 2 [IQR 1-4]). Most statements were nonprobabilistic (316/512 [62%]); 10 of 512 prognostic statements (2%) offered numeric estimates; and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared with statements about cognition, statements about survival (odds ratio [OR] 2.50, 95% CI 1.01-6.18, p = 0.048) and physical function (OR 3.22, 95% 1.77-5.86, p < 0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34, 95% CI 0.17-0.66, p = 0.002). DISCUSSION Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness.
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Affiliation(s)
- Adeline Goss
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Connie Ge
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
| | - Sybil Crawford
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Kelsey Goostrey
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Praewpannanrai Buddadhumaruk
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Catherine L Hough
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Bernard Lo
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Shannon Carson
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Jay Steingrub
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Douglas B White
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Susanne Muehlschlegel
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
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Jaffa MN, Hwang DY. Goals of Care for Severe Acute Brain Injury Patients: When a Choice Is Not a Choice. Crit Care Med 2023; 51:978-980. [PMID: 37318295 DOI: 10.1097/ccm.0000000000005879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT
| | - David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC
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Hernandez SF, Agarwal S. Decoding code status after cardiac arrest. Resuscitation 2022; 181:37-39. [PMID: 36272617 DOI: 10.1016/j.resuscitation.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sachin Agarwal
- Department of Neurology, Division of Critical Care & Hospitalist Neurology, Columbia University Irving Medical Center & New York Presbyterian Hospital, New York, United States.
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Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Chiang MC, Huang CC, Hu TH, Chou WC, Chuang LP, Tang ST. Factors associated with bereaved family surrogates' satisfaction with end-of-life care in intensive care units. Intensive Crit Care Nurs 2022; 71:103243. [PMID: 35396097 DOI: 10.1016/j.iccn.2022.103243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Family satisfaction with end-of-life care in the intensive care unit constitutes an important outcome for evaluating end-of-life care quality. Research on this topic focuses on linking end-of-life care processes to family-surrogate satisfaction with the patient's end-of-life care but has seldom examined patient- and family-surrogate-based factors. We aimed to comprehensively and simultaneously examine factors facilitating or deterring family satisfaction with end-of-life care in the intensive care unit from patient- and family-surrogate perspectives. METHODS For this secondary-analysis study, 278 Taiwanese family surrogates were surveyed one-month post-patient death using the Family Satisfaction in the Intensive Care Unit questionnaire (FS-ICU), which measures care and decision-making. Associations between family satisfaction with end-of-life care and patient and family characteristics, patient disease severity, and length of intensive care stay were examined by multivariate, multilevel linear regression models. RESULTS Female family surrogates were more satisfied with patients' end-of-life care than male family surrogates when patients had a higher APACHE II but a lower SOFA score. Adult-child surrogates had lower FS-ICU Care scores than other family surrogates. Higher satisfaction with ICU decision-making was associated with patients' higher APACHE II but lower SOFA scores, longer stay and family socio-demographics, including being unmarried, educational attainment above junior high school and reported financial sufficiency to make ends meet. CONCLUSION Patient disease severity and family-surrogate characteristics are significantly associated with surrogates' satisfaction with patients' end-of-life care in the intensive care unit. Specific interventions should be tailored to the needs of high-risk family surrogates to increase their satisfaction with this care.
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Affiliation(s)
- Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Taiwan, ROC
| | - Chung-Chi Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, ROC
| | - Tsung-Hui Hu
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, ROC
| | - Li-Pang Chuang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC
| | - Siew Tzuh Tang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Taiwan, ROC; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, ROC.
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Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study. Crit Care Explor 2022; 4:e0640. [PMID: 35224505 PMCID: PMC8863127 DOI: 10.1097/cce.0000000000000640] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE: Withdrawal-of-life-sustaining treatments (WOLST) rates vary widely among critically ill neurologic patients (CINPs) and cannot be solely attributed to patient and family characteristics. Research in general critical care has shown that clinicians prognosticate to families with high variability. Little is known about how clinicians disclose prognosis to families of CINPs, and whether any associations exist with WOLST. OBJECTIVES: Primary: to demonstrate feasibility of audio-recording clinician-family meetings for CINPs at multiple centers and characterize how clinicians communicate prognosis during these meetings. Secondary: to explore associations of 1) clinician, family, or patient characteristics with clinicians’ prognostication approaches and 2) prognostication approach and WOLST. DESIGN, SETTING, AND PARTICIPANTS: Forty-three audio-recorded clinician-family meetings during which prognosis was discussed from seven U.S. centers for 39 CINPs with 88 family members and 27 clinicians. MAIN OUTCOMES AND MEASURES: Two investigators qualitatively coded transcripts using inductive methods (inter-rater reliability > 80%) to characterize how clinicians prognosticate. We then applied univariate and multivariable multinomial and binomial logistic regression. RESULTS: Clinicians used four distinct prognostication approaches: Authoritative (21%; recommending treatments without discussing values and preferences); Informational (23%; disclosing just the prognosis without further discussions); advisory (42%; disclosing prognosis followed by discussion of values and preferences); and responsive (14%; eliciting values and preferences, then disclosing prognosis). Before adjustment, prognostication approach was associated with center (p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists; p = 0.001), patient age (p = 0.08), diagnosis (p = 0.059), and meeting length (p = 0.03). After adjustment, only clinician specialty independently predicted prognostication approach (p = 0.027). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). WOLST was more likely in older patients (p = 0.059) and with more experienced clinicians (p = 0.07). Prognostication approach was not independently associated with WOLST (p = 0.198). CONCLUSIONS AND RELEVANCE: It is feasible to audio-record sensitive clinician-family meetings about CINPs in multiple ICUs. We found that clinicians prognosticate with high variability. Our data suggest that larger studies are warranted in CINPs to examine the role of clinicians’ variable prognostication in WOLST decisions.
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Lin Q, Dong F, Xue Y, Yu Q, Ren J, Zeng L. Predictors of posttraumatic growth of the family members of neurosurgical intensive care unit patients: A cross-sectional study. Intensive Crit Care Nurs 2021; 68:103134. [PMID: 34750040 DOI: 10.1016/j.iccn.2021.103134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/26/2021] [Accepted: 08/12/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Confronted with the potentially traumatic experience of a patients intensive care unit hospitalisation, family members may show positive changes associated with growth in addition to negative impact. This study aimed to identify the level of posttraumatic growth of the family members of neurosurgical intensive care unit patients and to explore its relation to positive personality characteristics, such as gratitude, resilience and hope. DESIGN AND SETTING A cross-sectional study involving 340 family members of patients admitted to the neurosurgical intensive care unit at a general tertiary hospital in Shanghai, China. METHODS Before the patients' hospital discharge, the participants completed questionnaires, assessing posttraumatic growth (PTG Inventory), social support (Social Support Rating Scale), resilience (Chinese version of the Connor-Davidson Resilience Scale), hope (Herth Hope Index) and gratitude (Gratitude Questionnaire Six-Item Form). RESULTS The mean total posttraumatic growth score was 73.38 (14.02). Hope, gratitude, resilience and social support showed a positive correlation with the posttraumatic growth Inventory scores. There were significant differences in the posttraumatic growth scores of the family members of neurosurgical intensive care patients with respect to their different religious beliefs, payment methods, family relationship quality and presence of chronic diseases among family members. Multiple linear regression analysis showed that gratitude, resilience and social support were independent predictors of the posttraumatic growth Inventory score. CONCLUSION Family members may experience some degree of posttraumatic growth during hospitalisation of patients in the neurosurgical intensive care units. Gratitude, social support and resilience are predictive factors for posttraumatic growth.
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Affiliation(s)
- Qi Lin
- Department of Nursing, Shanghai Jiao Tong University Affiliated Sixth People's Hospital. Shanghai, China
| | - Fanghui Dong
- Department of Nursing, Shanghai Jiao Tong University Affiliated Sixth People's Hospital. Shanghai, China
| | - Yiwei Xue
- Intensive Care Unit, Shanghai Jiao Tong University Affiliated Sixth People's Hospital. Shanghai, China
| | - Qunya Yu
- General Surgery Department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital. Shanghai, China
| | - Junhong Ren
- Ophthalmology Department, Shanghai Tenth People's Hospital, School of Medicine, Tongji University. Shanghai, China
| | - Li Zeng
- Neurosurgical Intensive Care Unit, Shanghai Tenth People's Hospital, School of Medicine, Tongji University. Shanghai, China; Department of Nursing, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.
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Gao L, Zhao CW, Hwang DY. End-of-Life Care Decision-Making in Stroke. Front Neurol 2021; 12:702833. [PMID: 34650502 PMCID: PMC8505717 DOI: 10.3389/fneur.2021.702833] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/31/2021] [Indexed: 12/21/2022] Open
Abstract
Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.
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Affiliation(s)
- Lucy Gao
- Yale School of Medicine, New Haven, CT, United States
| | | | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, United States
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11
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Wijdicks EFM, Hwang DY. Predicting Coma Trajectories: The Impact of Bias and Noise on Shared Decisions. Neurocrit Care 2021; 35:291-296. [PMID: 34426900 PMCID: PMC8382106 DOI: 10.1007/s12028-021-01324-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
Coma trajectories are characterized by quick awakening or protracted awakening. Outcome is bookended by restored functionality or permanent cognitively and physically debilitated states. Given the stakes, prognostication cannot be easily questioned as a judgment call, and a scientific underpinning is elemental. Conventional wisdom in determining coma-outcome trajectories posits that (1) predictive models are better than personal experiences, (2) self-fulfilling prophesy is unchecked and driven by nihilism, with little regard for prior probability outcomes, and (3) recovery is impacted by patients’ prior wishes and preexisting medical conditions—but also by what families are told about the patient’s state and anticipated clinical course. Moreover, a predicted good outcome can be offset by a major subsequent complication, or a predicted poor outcome can be offset by aggressive care. This article examines some of these concepts, including how we decide on aggressiveness of care, how we judge quality of life, and the impact on outcome. Most patients who awaken quickly do well and can resume their pretrauma injury lives. In worse off, slow-to-awaken patients, outcomes are a mixed bag of limited innate resilience, depleted cognitive and physical reserves, and adjusted quality of life. Bias and noise are factors not easily measured in outcome prediction, but their influence on recovery trajectories raises some troubling issues.
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Affiliation(s)
- Eelco F M Wijdicks
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA. .,Yale New Haven Hospital, New Haven, CT, USA. .,Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - David Y Hwang
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA.,Yale New Haven Hospital, New Haven, CT, USA
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