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Abstract Details

How Physicians Disclose Prognostic Information to Surrogates of Patients with Critical Neurologic Illness – a Pilot Multi-center Qualitative Analysis
Neuro Trauma, Critical Care, and Sports Neurology
S48 - Neurocritical Care: Traumatic Brain Injury and Goals-of-care Decision-making (1:36 PM-1:48 PM)
004
To characterize the language physicians use to disclose prognosis to surrogates of critically ill neurologic patients (CINP) and relate that language to the types of outcomes discussed.
Physician communication about prognosis is an essential component of shared decision-making for patients with critical neurologic illness, yet little is known about how physicians disclose different aspects of neurologic prognosis.
We qualitatively analyzed 35 physician-family conferences from seven U.S. centers wherein prognostic information was offered for 31 unique CINP with primary neurologic diagnoses. Through an inductive and iterative process using constant comparative methods, two coders double-coded conference transcripts to correlate physicians’ prognostic statements with types of outcomes discussed, with excellent interrater reliability (kappa=0.86). 

443 prognostic statements were identified. Types of outcomes discussed included physical function (e.g. motor, swallowing[35%]), cognition (e.g. alertness, language[31%]), survival (11%), and unspecified outcomes (e.g. “recovery”[22%]).  More than half of all prognostic statements (68%) were non-probabilistic and described possible outcomes without defining their likelihood (22%) or described prognosis in uncertainty-based (24%), emotion-based (e.g. “worrisome”[13%]), or opinion-based terms (e.g. “I think...”[9%]). In contrast, probabilistic statements included absolute (e.g. “He will…”[16%]), qualitative (e.g. “probably”[15%]), and numerical estimates of prognosis (2%). Non-probabilistic prognostic statements represented 74% of statements about cognitive outcomes, compared to 60% of statements about survival (Fisher’s exact test, p=0.0975) and 55% of statements about physical functional outcomes (p=0.001). Uncertainty-based statements (e.g. “It’s kind of a waiting game”) represented 32% of statements about cognitive outcomes, compared to 17% of statements about survival (p=0.061) and 14% of statements about physical function (p<0.001).

In this pilot study, physicians rarely used numbers to convey prognosis to surrogates of CINP, instead favoring qualitative probabilistic or non-probabilistic statements, particularly when discussing cognitive outcomes. Our data suggests that physicians may feel less certain when prognosticating around cognitive outcomes, but further research to validate this hypothesis is required.
Authors/Disclosures
Adeline L. Goss, MD (Highland Hospital)
PRESENTER 		Dr. Goss has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Neurological Association.
Connie Ge, MD Ms. Ge has nothing to disclose.
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Susanne Muehlschlegel, MD, MPH, FAAN (Johns Hopkins School of Medicine) Dr. Muehlschlegel has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Acasti Pharma Inc.. Dr. Muehlschlegel has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Acasti Pharma Inc.. The institution of Dr. Muehlschlegel has received research support from NIH. The institution of Dr. Muehlschlegel has received research support from NIH. The institution of an immediate family member of Dr. Muehlschlegel has received research support from NIH. The institution of Dr. Muehlschlegel has received research support from Johns Hopkins Stimulating and Advancing Anesthesiology & Critical Care Medicine Research (StAAR) Award. The institution of Dr. Muehlschlegel has received research support from Trustees of The Patrick and Catherine Weldon Donaghue Medical Research Foundation. The institution of Dr. Muehlschlegel has received research support from Harkin Family Fund (Johns Hopkins Dept. of Neurology). Dr. Muehlschlegel has received personal compensation in the range of $500-$4,999 for serving as a Speaker and Author with 好色先生. Dr. Muehlschlegel has a non-compensated relationship as a Member of Board of Directors with Neurocritical Care Society that is relevant to AAN interests or activities.