Abstract 251: Approach to Prognostication for Patients Enrolled in a Post-Arrest Clinical Trial

Abstract

Introduction/Background: Neuroprognostication after cardiac arrest is complex and the way clinicians prognosticate is not well understood. Research Question/Hypothesis: How do clinicians describe their approach to post-arrest prognostication in general and in specific patients they have treated? Goals/Aims: Characterize one or more prevailing themes in clinical decision-making about neuroprognostication. Methods/Approach: We surveyed and performed semi-structured interviews with clinicians who had cared for a subject enrolled in the Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial (NCT04217551). We performed interviews after trial subject died or was discharged. Our interviews explored clinician’s approach to neuroprognostication. Two authors (AS and YY) independently performed thematic analysis using inductive coding, then discussed any discrepancies and reached a consensus. Early in coding, we identified “clinical gestalt” as a common theme, defined as prognosticating based on patients overall appearance or impression of their history in the absence of any definitive prognostic tests. Each clinician provided their demographic information and local standard practices. We presented emerging themes and discrete responses with descriptive statistics as appropriate. We did not have access to subjects’ clinical identifiers or treatment arm of the trial. Results/Data: We interviewed 30 clinicians, who practiced at 19 US hospitals. Clinicians were primarily attendings (n=20) and most practiced critical care (n=21). Many (21/30) clinicians reported using clinical gestalt to formulate their early impressions. Of these, 9/21 reported high certainty in their initial predictions. Clinical gestalt informed both prediction of good and poor outcomes. Clinicians described different ways of incorporating gestalt into prognostication, including arrest history (17/21), severity of initial shock or multi-system organ failure (13/21), past clinical experience (10/21), comorbidities (10/21), and patient physical appearance (6/21). Conclusion: Clinicians often use gestalt when formulating early impressions of patient’s prognosis, an approach rarely discussed in prognostication literature.