Predictors of Better Shared Decision Making in Goals-Of-Care Clinician-Family Meetings for Critically Ill Neurologic Patients: A Multi-Center Mixed Methods Pilot Study (S4.003)

Abstract

<h3>Objective:</h3> To characterize and quantify SDM in GOC meetings To identify factors associated with higher SDM score <h3>Background:</h3> Shared decision making (SDM) is recommended by experts to improve difficult decisions in ICUs; yet for the most difficult decision of all, the goals-of-care (GOC) decision, empirical research in medical-surgical ICUs demonstrated that only 2% of clinician-family meetings contained all SDM elements. Little is known about the extent and predictors of SDM in critically-ill neurological patients (CINPs). <h3>Design/Methods:</h3> Two qualitative coders applied a validated 10-element SDM instrument to 63 GOC clinician-family meetings for CINPs, audio-recorded at seven U.S. medical centers. Clinicians and families completed post-meeting questionnaires assessing their own prognostic estimates. We defined the Clinician-Family-Prognostic-Discordance-Score as the difference between both estimates and prognostic discordance as ≥20% difference. We applied univariate and multivariable longitudinal regression to identify predictors of more SDM. <h3>Results:</h3> The median SDM score (total number of unique SDM elements per meeting) was 7 (range 1–10; IQR 5–8). Only 6% of meetings contained all 10 SDM elements. The most common SDM elements were “<i>discussing uncertainty”</i>(89%) and <i>“assessing family understanding”</i>(86%); the least frequent elements were <i>“assessing the need for input from others”</i>(40%) and <i>“eliciting the context of the decision”</i>(32%). Prognostic discordance was 60% and 45% for hospital-survival and 6-month independent functioning, respectively. In univariate analyses, more SDM was associated with female clinicians, and Cohort 2. Meetings with less clinician-surrogate survival discordance approached significance. After adjustment, there was a trend towards clinician gender being an independent predictor of more SDM(p=0.11), but none of the variables were independent predictors. <h3>Conclusions:</h3> Few clinician-family GOC-meetings for CINPs contained all SDM elements. We uncovered modifiable gaps as opportunities for improvement. While our sample was too small to find independent predictors of SDM, our data supports the urgent need to continue our mixed-method of examination of clinician-family GOC-meetings in larger cohorts. <b>Disclosure:</b> Miss Fleming has nothing to disclose. Mr. Prasad has nothing to disclose. Ms. Ge has nothing to disclose. Mr. Meraj has nothing to disclose. Miss Franco has received personal compensation for serving as an employee of Umass Medical School. The institution of Catherine Hough has received research support from NIH. Bernard Lo has nothing to disclose. Shannon Carson has nothing to disclose. The institution of Jay Steingrub has received research support from NHLBI. Douglas White 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 uptodate. Douglas White 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 Journal of Respiratory and Critical Care Medicine. 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. 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.