Shared Decision-Making Communication and Prognostic Misunderstanding in the ICU
Authors: Vick Judith B. , Berger Benjamin T. , Ubel Peter A. , Cox Christopher E. , You HyunBin , Ma Jessica E. , Haverfield Marie C. , Hammill Bradley G. , Carson Shannon S. , Hough Catherine L. , White Douglas B. , Ashana Deepshikha Charan 
Published: October 2024

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.