Effect of Documenting Prognosis on the Information Provided to ICU Proxies: A Randomized Trial

Abstract

Objectives: The Critical Care Choosing Wisely Task Force recommends that intensivists offer patients at high risk for death or severe functional impairment the option of pursuing care focused on comfort. We tested the a priori hypothesis that intensivists who are prompted to document patient prognosis are more likely to disclose prognosis and offer comfort-focused care.

Design: Randomized controlled trial (clinicaltrials.gov: NCT02721810).

Setting: High-fidelity Simulation Center in Baltimore, MD.

Participants: One hundred sixteen intensivists from 17 states.

Intervention: All intensivists reviewed a paper-based medical record for a hypothetical patient on ICU day 3 and answered four survey questions about the patient's medical management. Intensivists randomized to the intervention group answered three additional questions about patient prognosis. Thereafter, each intensivist participated in a standardized, video-recorded, simulated family meeting with an actor performing a standardized portrayal of the patient's daughter.

Measurements and main results: Two blinded intensivists reviewed deidentified written transcripts of all simulated family meetings. The primary outcome was the blinded reviewers' assessment that the intensivist had presented the option of care focused entirely on comfort. Secondary outcomes included disclosing risk of death. All outcomes were planned prior to data collection. Among the 63 intensivists randomized to the intervention, 50 (79%) expected the patient to die during the hospitalization and 58 (92%) expected the patient to have new functional impairments preventing independent living. Intensivists in the intervention versus control group were no more likely to offer the option of care focused on comfort (13% vs 13%; 95% CI, -13% to 12%; p = 1.0) but were more likely to inform the daughter that her father was sick enough to die (68% vs 43%; 95% CI, 5-44%; p = 0.01).

Conclusions: Documenting prognosis may help intensivists disclose prognosis to ICU proxies, but in isolation, it is unlikely to change the treatment options offered during initial family meetings.

Figure 1.

Data collection. A, Data on intensivist characteristics were collected via an online survey. Eligible intensivists then traveled to the Simulation Center where they reviewed the medical record of the hypothetical patient and were randomized (B1) to document their medical management plan or (B2) to document their medical management plan as well as estimates of the patient’s prognosis for in-hospital survival and 3-mo functional prognosis. C, Each intensivist then participated in a standardized, video- and audio-recorded, simulated family meeting with a trained actor portraying the patient’s daughter. D, Immediately following the simulation intensivists self-reported their own communication behaviors during the simulated meeting via a computer-based survey. E, Audio recordings of the meetings were transcribed and deidentified by a medical transcriptionist. F, Two blinded reviewers (both attending intensivists) independently read the resulting transcripts and assessed whether participating intensivists disclosed prognosis and offered the option of care focused on comfort during the simulated family meeting.

Figure 2.

Flow of intensivists through the Simulated Communication with ICU Proxies (SCIP) trial.