Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study

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.

Figure 1. Flow Diagram Describing Patient Enrollment

Cohort 1 included a subset of patients with critical neurologic illness from a parent multicenter study at 6 academic centers on clinician-family communication. Cohort 2 included patients from a neuro-trauma ICU at a single academic center. Baystate = University of Massachusetts Chan Medical School—Baystate; Harborview = Harborview Medical Center; ICU = intensive care unit; UCSF = University of California San Francisco; UCSF-Fresno = University of California San Francisco-Fresno; UMMS = University of Massachusetts Chan Medical School; UNC = University of North Carolina Medical Center; UPMC = University of Pittsburgh Medical Center.

Figure 2. Breakdown of Probabilistic and Nonprobabilistic Statements by Domain of Prognosis

In the multivariable analysis, compared with statements describing cognition, statements about survival (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 likely to be probabilistic. Statements concerning 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). There was no significant difference in the proportion of probabilistic statements about survival compared with physical function or the proportion of uncertainty statements about survival compared with cognition or physical function. OR = odds ratio.