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. 2024 Oct 1;7(10):e2439715.
doi: 10.1001/jamanetworkopen.2024.39715.

Shared Decision-Making Communication and Prognostic Misunderstanding in the ICU

Judith B Vick  1   2   3 , Benjamin T Berger  1 , Peter A Ubel  1   4 , Christopher E Cox  1 , HyunBin You  5 , Jessica E Ma  1   6 , Marie C Haverfield  7 , Bradley G Hammill  1   4 , Shannon S Carson  8 , Catherine L Hough  9 , Douglas B White  10 , Deepshikha Charan Ashana  1   4   11
Affiliations

Shared Decision-Making Communication and Prognostic Misunderstanding in the ICU

Judith B Vick et al. JAMA Netw Open. .

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Ma reported receiving grants from the University of Michigan HEAL during the conduct of the study. Dr Carson reported grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Hough reported grants from NIH, grants from American Lung Association, and grants from the US Centers for Disease Control and Prevention outside the submitted work. Dr White reported grants from NIH during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Surrogate Misunderstanding of Physician Estimates of Survival Prognosis
This figure illustrates that surrogate-clinician prognostic discordance can come from 2 sources: (1) surrogate misunderstanding of the clinician’s prognostic estimate and (2) surrogate disagreement with their perception of the clinician’s estimate. Surrogate misunderstanding of the clinician’s prognostic estimate is the absolute value of the clinician’s prognostic estimate (C) minus the surrogate’s perception of the clinician’s prognostic estimate (Sc). Please note that this figure is illustrative only and not based on the data included in our analysis. S indicates surrogate prognostic estimate.
Figure 2.
Figure 2.. Shared Decision-Making–Aligned Communication Behaviors
Shared decision-making–aligned communication behaviors were identified in a prior summative content analysis using a codebook adapted from a shared decision-making–based scoring schema that found that these communication behaviors were associated with goal-concordant care delivery during a simulated clinical scenario involving a critically ill patient.
Figure 3.
Figure 3.. Premeeting and Postmeeting Surrogate and Physician Misunderstanding of Other’s Prognostic Estimate
A and B, Median surrogate misunderstanding decreased by 7.0 percentage points. A Wilcox signed rank test showed that there was a significant difference (Z = 3.07; P = .002) between premeeting surrogate misunderstanding and postmeeting surrogate misunderstanding. C and D, Median physician misunderstanding increased by 3.0 percentage points. A Wilcox signed rank test showed that there was not a significant difference (Z = −0.02; P = .99) between premeeting physician misunderstanding and postmeeting physician misunderstanding.
Figure 4.
Figure 4.. Association of Shared Decision-Making (SDM)–Aligned Communication and Surrogate and Physician Prognostic Misunderstanding
pp Indicates percentage point.
See this image and copyright information in PMC

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