Assessment of Discordance Between Physicians and Family Members Regarding Prognosis in Patients With Severe Acute Brain Injury
Authors: Whitney A. Kiker, Rachel Rutz Voumard, Leah I. B. Andrews, Robert G. Holloway, Lyndia C. Brumback, Ruth A. Engelberg, J. Randall Curtis, Claire J. Creutzfeldt
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Shared decision-making requires key stakeholders to align in perceptions of prognosis and likely treatment outcomes. <h3>Objective</h3> For patients with severe acute brain injury, the objective of this study was to better understand prognosis discordance between physicians and families by determining prevalence and associated factors. <h3>Design, Setting, and Participants</h3> This mixed-methods cross-sectional study analyzed a cohort collected from January 4, 2018, to July 22, 2020. This study was conducted in the medical and cardiac intensive care units of a single neuroscience center. Participants included families, physicians, and nurses of patients admitted with severe acute brain injury. <h3>Exposures</h3> Severe acute brain injury was defined as stroke, traumatic brain injury, or hypoxic ischemic encephalopathy with a Glasgow Coma Scale score less than or equal to 12 points after hospital day 2. <h3>Main Outcomes and Measures</h3> Prognosis discordance was defined as a 20% or greater difference between family and physician prognosis predictions; misunderstanding was defined as a 20% or greater difference between physician prediction and the family's estimate of physician prediction; and optimistic belief difference was defined as any difference (&gt;0%) between family prediction and their estimate of physician prediction. Logistic regression was used to identify associations with discordance. Optimistic belief differences were analyzed as a subgroup of prognosis discordance. <h3>Results</h3> Among 222 enrolled patients, prognostic predictions were available for 193 patients (mean [SD] age, 57 [19] years; 106 men [55%]). Prognosis discordance occurred for 118 patients (61%) and was significantly more common among families who identified with minoritized racial groups compared with White families (odds ratio [OR], 3.14; CI, 1.40-7.07,<i>P</i> = .006); among siblings (OR, 4.93; 95% CI, 1.35-17.93,<i>P</i> = .02) and adult children (OR, 2.43; 95% CI, 1.10-5.37;<i>P</i> = .03) compared with spouses; and when nurses perceived family understanding as poor compared with good (OR, 3.73; 95% CI, 1.88-7.40;<i>P</i> &lt; .001). Misunderstanding was present for 80 of 173 patients (46%) evaluated for this type of prognosis discordance, and optimistic belief difference was present for 94 of 173 patients (54%). In qualitative analysis, faith and uncertainty emerged as themes underlying belief differences. Nurse perception of poor family understanding was significantly associated with misunderstanding (OR, 2.06; 95% CI, 1.07-3.94;<i>P</i> = .03), and physician perception with optimistic belief differences (OR, 2.32; 95% CI, 1.10-4.88;<i>P</i> = .03). <h3>Conclusions and Relevance</h3> Results of this cross-sectional study suggest that for patients with severe acute brain injury, prognosis discordance between physicians and families was common. Efforts to improve communication and decision-making should aim to reduce this discordance and find ways to target both misunderstanding and optimistic belief differences.