Surrogate Decision Makers' Perspectives on Family Members' Prognosis after Intracerebral Hemorrhage.

BACKGROUND: Surrogate communication with providers about prognosis in the setting of acute critical illness can impact both patient treatment decisions and surrogate outcomes. OBJECTIVES: To examine surrogate decision maker perspectives on provider prognostic communication after intracerebral hemorrhage (ICH). DESIGN: Semistructured interviews were conducted and analyzed qualitatively for key themes. SETTING/SUBJECTS: Surrogate decision makers for individuals admitted with ICH were enrolled from five acute care hospitals. RESULTS: Fifty-two surrogates participated (mean age = 54, 60% women, 58% non-Hispanic white, 13% African American, 21% Hispanic). Patient status at interview was hospitalized (17%), in rehabilitation/nursing facility (37%), deceased (38%), hospice (4%), or home (6%). Nineteen percent of surrogates reported receiving discordant prognoses, leading to distress or frustration in eight cases (15%) and a change in decision for potentially life-saving brain surgery in three cases (6%). Surrogates were surprised or confused by providers' use of varied terminology for the diagnosis (17%) (e.g., "stroke" vs. "brain hemorrhage" or "brain bleed") and some interpreted "stroke" as having a more negative connotation. Surrogates reported that physicians expressed uncertainty in prognosis in 37%; with physician certainty in 56%. Surrogate reactions to uncertainty were mixed, with some surrogates expressing a negative emotional response (e.g., anxiety) and others reporting understanding or acceptance of uncertainty. CONCLUSIONS: Current practice of prognostic communication in acute critical illness has many gaps, leading to distress for surrogates and variability in critical treatment decisions. Further work is needed to limit surrogate distress and improve the quality of treatment decisions.

Variability in physician prognosis and recommendations after intracerebral hemorrhage.

OBJECTIVE: To assess physician prognosis and treatment recommendations for intracerebral hemorrhage (ICH) and to determine the effect of providing physicians a validated prognostic score. METHODS: A written survey with 2 ICH scenarios was completed by practicing neurologists and neurosurgeons. Selected factors were randomly varied (patient older vs middle age, Glasgow Coma Scale [GCS] score 7T vs 11, and presence vs absence of a validated prognostic score). Outcomes included predicted 30-day mortality and recommendations for initial treatment intensity (6-point scale ranging from 1 = comfort only to 6 = full treatment). RESULTS: A total of 742 physicians were included (mean age 52, 32% neurosurgeons, 17% female). Physician predictions of 30-day mortality varied widely (mean [range] for the 4 possible combinations of age and GCS were 23% [0%-80%], 35% [0%-100%], 48% [0%-100%], and 58% [5%-100%]). Treatment recommendations also varied widely, with responses encompassing the full range of response options for each case. No physician demographic or personality characteristics were associated with treatment recommendations. Providing a prognostic score changed treatment recommendations, and the effect differed across cases. When the prognostic score suggested 0% chance of functional independence (76-year-old with GCS 7T), the likelihood of treatment limitations was increased (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.12-2.33) compared to no prognostic score. Conversely, if the score suggested a 66% chance of independence (63-year-old with GCS 11), treatment limitations were less likely (OR 0.62, 95% CI 0.43-0.88). CONCLUSIONS: Physicians vary substantially in ICH prognostic estimates and treatment recommendations. This variability could have a profound effect on life and death decision-making and treatment for ICH.