Original Investigation
Critical Care Medicine
October 15, 2024
Shared Decision-Making Communication and Prognostic Misunderstanding in the ICU
Judith B. Vick, Benjamin T. Berger, Peter A. Ubel, et al
JAMA Netw Open. 2024;7(10):e2439715.
doi:10.1001/jamanetworkopen.2024.39715
Question Are shared decision-making (SDM) behaviors in the intensive care unit (ICU) associated with reduced misunderstanding of survival prognosis?
Findings In this cohort study including 137 ICU family meetings, SDM-aligned communication was not significantly associated with reduced prognostic misunderstanding among surrogates or physicians in the full cohort. However, SDM-aligned communication was associated with reduced surrogate prognostic misunderstanding in a subgroup of surrogates with baseline clinically significant misunderstanding.
Meaning These findings suggest that for surrogates who have clinically significant prognostic misunderstanding, SDM-aligned communication may reduce prognostic misunderstanding.
Abstract
Importance Surrogate misunderstanding of patient survival prognosis in the intensive care unit (ICU) is associated with poor patient and surrogate outcomes. Shared decision-making (SDM) may reduce misunderstanding.
Objective To evaluate the association between SDM-aligned communication and prognostic misunderstanding.
Design, Setting, and Participants This retrospective cohort study was conducted at 13 medical and surgical ICUs at 5 hospitals in North Carolina, Pennsylvania, and Washington between December 2012 and January 2017. Participants were surrogates of adult patients receiving prolonged mechanical ventilation and ICU physicians. Analysis was performed May to November 2023.
Exposure SDM-aligned communication during ICU family meetings, defined as the presence of high-quality serious illness communication behaviors aligned with SDM principles.
Main Outcomes and Measures The primary outcome was postmeeting surrogate prognostic misunderstanding, defined as the absolute difference between the physician’s estimate of survival prognosis and the surrogate’s perception of that estimate (range, 0-100 percentage points). The secondary outcome was postmeeting physician misunderstanding, defined as the absolute difference between a surrogate’s estimate of survival prognosis and the physician’s perception of that estimate (range, 0-100 percentage points). Prognostic misunderstanding of 20 percentage points or greater was considered clinically significant as in prior work.
Results Of 137 surrogates, most were female (102 [74.5%]), and there were 22 (16.1%) Black surrogates, 107 (78.1%) White surrogates, and 8 surrogates (5.8%) with other race and ethnicity. Of 100 physicians, most were male (64 [64.0%]), with 11 (11.0%) Asian physicians, 4 (4.0%) Black physicians, and 75 (75.0%) White physicians. Median (IQR) surrogate prognostic misunderstanding declined significantly after family meetings (before: 22.0 [10.0 to 40.0] percentage points; after: 15.0 [5.0 to 34.0] percentage points; P = .002), but there was no significant change in median (IQR) physician prognostic misunderstanding (before: 12.0 [5.0 to 30.0] percentage points; after: 15.0 [5.0 to 29.0] percentage points; P = .99). In adjusted analyses, SDM-aligned communication was not associated with prognostic misunderstanding among surrogates or physicians (surrogates: β = −0.74; 95% CI, −1.81 to 0.32; P = .17; physicians: β = −0.51; 95% CI, −1.63 to 0.62; P = .38). In a prespecified subgroup analysis of 78 surrogates (56.9%) with clinically significant premeeting prognostic misunderstanding, SDM-aligned communication was associated with reduced surrogate postmeeting prognostic misunderstanding (β = −1.71; 95% CI, −3.09 to −0.34; P = .01).
Conclusions and Relevance In this retrospective cohort study, SDM-aligned communication was not associated with changes in prognostic misunderstanding for all surrogates or physicians, but it was associated with reduced prognostic misunderstanding among surrogates with clinically significant misunderstanding at baseline.
