Prognosis discordant is common between families and physicians for patients with severe acute brain injury and their likelihood of recovering to independence, according to study results published in JAMA Network Open.
In many cases, patients with severe acute brain injury – a group of neurologic conditions that include stroke, traumatic brain injury, and hypoxic ischemic encephalopathy – are unable to participate in the decision-making process regarding their treatment, leaving the decision to their family members.
As limited data are available on differences regarding prognostic estimates between physicians and families specific to severe acute brain injury, the current study aimed at assessing the prevalence and etiology of discordance between parties.
The cross-sectional study included 193 patients (mean age, 57 years; 55% men) with severe acute brain injury, including stroke, traumatic brain injury, or hypoxic ischemic encephalopathy with a Glasgow Coma Scale score ≤ 12 points after hospital day 2.
Between hospital days 2 and 7, family members were invited to complete a survey with 3 questions regarding the patient’s prognosis. On the same day, the attending physician was asked to predict the patient’s prognosis. Furthermore, families were asked to estimate what the attending physician would predict if asked the same question, and the physicians were asked to rate the quality of the family’s understanding of prognosis on a 5-point Likert scale.
A difference between family and physician prognosis predictions of ≥ 20% was defined as prognosis discordance. A difference between physician prediction and the family’s estimate of physician prediction of ≥ 20% was defined as misunderstanding. Optimistic belief difference was defined as a family member’s own prediction that was greater than what they estimated the physician would predict.
Overall prognosis discordance between parties was common and documented for 118 of 193 patients (61%) and misunderstanding occurred for 80 of 173 patients (46%). Optimistic prognosis discordance, in which families were more optimistic than the physician, was reported for 99 (84%) patients, while pessimistic discordance was reported for 19 (16%) patients.
Families who identified as minoritized racial groups were 3-times more likely to experience overall prognosis discordance than White family members (odds ratio [OR], 3.14; 95% CI, 1.40-7.07; P =.006). The risk for prognostic discordance was increased by almost 5-fold for siblings (OR, 4.93; 95% CI, 1.35-17.93; P =.02) and by more than 2-fold (OR, 2.43; 95% CI, 1.10-5.37; P =.03) for adult children, compared with spouses.
Physician rating of poor family understanding of prognosis was associated with optimistic belief difference (OR, 2.32; 95% CI, 1.10-4.88; P =.03), suggesting that physicians may misinterpret optimism or hope as a lack of understanding. On the other hand, nurse rating of poor understanding was associated with overall prognosis discordance (OR, 3.73; 95% CI, 1.88-7.40; P <.001) and with misunderstanding (OR, 2.06; 95% CI, 1.10-4.88; P =.03) but not with optimistic belief difference, suggesting that nurses may more accurately identify misunderstanding.
The study had several limitations, including limited generalizability due to using data from a single hospital in the US, collection of data early during the hospital stay with no data on predicted prognosis at a later stage. Also, the collection of data from a single attending physician and a single family member with no information on potential variability of predicted prognosis between physicians and between family members presented another study limitation.
“The results of this cross-sectional study suggest that prognosis discordance, which may hamper the shared decision-making process, is common between families and physicians for patients with severe acute brain injury,” concluded the researchers.
Kiker WA, Rutz Voumard R, Andrews LIB, et al. Assessment of discordance between physicians and family members regarding prognosis in patients with severe acute brain injury. JAMA Netw Open. Published online October 1, 2021. doi: 10.1001/jamanetworkopen.2021.28991