“Can’t You Just Say?” – Contrasting Communication Preferences between Surrogate Decision-Makers and Physicians during Outcome Prognostication in Critically-Ill Traumatic Brain Injury Patients

Objective: Surrogate decision-makers (“surrogates”) and physicians of incapacitated patients have different views of prognosis and how it should be communicated, but this has not been investigated in neurocritically-ill patients. We examined communication preferences in surrogates and physician practices during the outcome prognostication for critically-ill traumatic brain injury (ciTBI) patients in neuroICUs. Design: Qualitative study using in-person semi-structured interviews with surrogates of ciTBI patients and physicians with expertise in TBI. Setting: Two neuroICUs at two level-1 trauma centers (surrogates); seven academic U.S. medical centers (physicians). Subjects: Sixteen surrogates for 15 ciTBI patients and 20 attending physicians from neurocritical care, neurosurgery, trauma and palliative care. Interventions: Not applicable. Measurements and Main Results: We used qualitative content analysis and descriptive statistics of transcribed interviews to identify themes in surrogates and physicians. The majority of surrogates (82%) preferred numeric estimates describing the patient’s prognosis, as they felt it would limit prognostic uncertainty, which, in turn, surrogates perceived as frustrating. On the other hand, 75% of the physicians reported intentionally omitting numeric estimates during prognostication meetings due to low confidence in family members’ abilities to appropriately interpret probabilities, worry about creating false hope, and distrust in the accuracy and data quality of existing TBI outcome models. Physicians felt that TBI outcome models are for research only and should not be applied to individual patients. Surrogates valued compassion during prognostication discussions, and acceptance of their goals-of-care decision by clinicians. Physicians and surrogates agreed on avoiding false hope. Conclusions: We identified fundamental differences in preferences for the communication of prognostic information between surrogates of ciTBI patients and physicians during goals-of-care discussions. A decision aid could potentially bridge this chasm by providing surrogates consistent and patient-centered information, however, with qualitative rather than quantitative estimates of ciTBI prognosis and an open disclosure of uncertainty

Variable Knowledge, Use and Perceptions of the IMPACT Model among Physicians during Prognostication Meetings for Critically-ill Traumatic Brain Injury Patients – Results from a Qualitative Study

Introduction: The International Patient Decision Aid Standards, a framework for the creation of high-quality decision aids, calls for the presentation of probabilities. To inform the content of a goals-of-care decision aid in critically-ill TBI (ciTBI) patients, we examined physician’s awareness, perceptions, and use of the IMPACT-model, the most widely validated ciTBI outcome model, and explored their preferences for communicating prognostic information towards families. Methods: We conducted a qualitative study using semi-structured interviews in 20 attending physicians (neurocritical care, neurosurgery, trauma, palliative care) at 7 U.S. academic medical centers. We used descriptive statistics and performed qualitative content analysis of transcribed interviews to identify major themes. Results: Only 12 physicians (60%) expressed awareness of the IMPACT-model; two stated that they “barely” knew the model. Seven physicians indicated using the model at least some of the time in clinical practice, although none used it exclusively to derive a patient’s prognosis. Four major themes emerged: the IMPACT-model is intended for research but should not be applied to individual patients; mistrust in the IMPACT-model derivation data; the IMPACT-model is helpful in reducing prognostic variability among physicians; concern that statistical models may mislead families about a patient’s prognosis. Conclusions: We identified substantial variability in the awareness of, use, and attitude toward the IMPACT model among physicians. Understanding knowledge, use, and barriers to using existing models, like IMPACT, is vital for creating and implementing a meaningful shared decision-making tool to improve goals-of-care discussions

Should We Use the IMPACT-Model for the Outcome Prognostication of TBI Patients? A Qualitative Study Assessing Physicians\u27 Perceptions

Introduction. Shared Decision-Making may facilitate information exchange, deliberation, and effective decision-making, but no decision aids currently exist for difficult decisions in neurocritical care patients. The International Patient Decision Aid Standards, a framework for the creation of high-quality decision aids (DA), recommends the presentation of numeric outcome and risk estimates. Efforts are underway to create a goals-of-care DA in critically-ill traumatic brain injury (ciTBI) patients. To inform its content, we examined physicians\u27 perceptions, and use of the IMPACT-model, the most widely validated ciTBI outcome model, and explored physicians\u27 preferences for communicating prognostic information towards families. Methods. We conducted a qualitative study using semi-structured interviews in 20 attending physicians (neurosurgery,neurocritical care,trauma,palliative care) at 7 U.S. academic medical centers. We used performed qualitative content analysis of transcribed interviews to identify major themes. Results. Only 12 physicians (60%) expressed awareness of the IMPACT-model; two stated that they barely knew the model. Seven physicians indicated using the model at least some of the time in clinical practice, although none used it exclusively to derive a patient\u27s prognosis. Four major themes emerged: the IMPACT-model is intended for research but should not be applied to individual patients; mistrust in the IMPACT-model derivation data; the IMPACT-model is helpful in reducing prognostic variability among physicians; concern that statistical models may mislead families about a patient\u27s prognosis. Discussion: Our study identified significant variability of the awareness, perception, and use of the IMPACT-model among physicians. While many physicians prefer to avoid conveying numeric prognostic estimates with families using the IMPACT-model, several physicians thought that they ground them and reduce prognostic variability among physicians. These findings may factor into the creation and implementation of future ciTBI-related DAs

Adapting a Traumatic Brain Injury Goals-of-Care Decision Aid for Critically Ill Patients to Intracerebral Hemorrhage and Hemispheric Acute Ischemic Stroke

Objectives: Families in the neurologic ICU urgently request goals-of-care decision support and shared decision-making tools. We recently developed a goals-of-care decision aid for surrogates of critically ill traumatic brain injury patients using a systematic development process adherent to the International Patient Decision Aid Standards. To widen its applicability, we adapted this decision aid to critically ill patients with intracerebral hemorrhage and large hemispheric acute ischemic stroke. Design: Prospective observational study. Setting: Two academic neurologic ICUs. Subjects: Twenty family members of patients in the neurologic ICU were recruited from July 2018 to October 2018. Interventions: None. Measurements and Main Results: We reviewed the existing critically ill traumatic brain injury patients decision aid for content and changed: 1) the essential background information, 2) disease-specific terminology to hemorrhagic stroke and ischemic stroke , and 3) disease-specific prognosis tailored to individual patients. We conducted acceptability and usability testing using validated scales. All three decision aids contain information from validated, disease-specific outcome prediction models, as recommended by international decision aid standards, including careful emphasis on their uncertainty. We replaced the individualizable icon arrays graphically depicting probabilities of a traumatic brain injury patient\u27s prognosis with icon arrays visualizing intracerebral hemorrhage and hemispheric acute ischemic stroke prognostic probabilities using high-quality disease-specific data. We selected the Intracerebral Hemorrhage Score with validated 12-month outcomes, and for hemispheric acute ischemic stroke, the 12-month outcomes from landmark hemicraniectomy trials. Twenty family members participated in acceptability and usability testing (n = 11 for the intracerebral hemorrhage decision aid; n = 9 for the acute ischemic stroke decision aid). Median usage time was 22 minutes (interquartile range, 16-26 min). Usability was excellent (median System Usability Scale = 84/100 [interquartile range, 61-93; with \u3e 68 indicating good usability]); 89% of participants graded the decision aid content as good or excellent, and greater than or equal to 90% rated it favorably for information amount, balance, and comprehensibility. Conclusions: We successfully adapted goals-of-care decision aids for use in surrogates of critically ill patients with intracerebral hemorrhage and hemispheric acute ischemic stroke and found excellent usability and acceptability. A feasibility trial using these decision aids is currently ongoing to further validate their acceptability and test their feasibility for use in busy neurologic ICUs

Investigating variation in replicability

Although replication is a central tenet of science, direct replications are rare in psychology. This research tested variation in the replicability of 13 classic and contemporary effects across 36 independent samples totaling 6,344 participants. In the aggregate, 10 effects replicated consistently. One effect – imagined contact reducing prejudice – showed weak support for replicability. And two effects – flag priming influencing conservatism and currency priming influencing system justification – did not replicate. We compared whether the conditions such as lab versus online or US versus international sample predicted effect magnitudes. By and large they did not. The results of this small sample of effects suggest that replicability is more dependent on the effect itself than on the sample and setting used to investigate the effect