Quality of communication in the ICU and surrogate's understanding of prognosis

Abstract

Objective: Although misperceptions about prognosis by surrogates in ICUs are common and influence treatment decisions, there is no validated, practical way to measure the effectiveness of prognostic communication. Surrogates' subjective ratings of quality of communication have been used in other domains as markers of effectiveness of communication. We sought to determine whether surrogates' subjective ratings of the quality of prognostic communication predict accurate expectation about prognosis by surrogates.

Design: We performed a cross-sectional cohort study. Surrogates rated the quality of prognostic communication by survey. Physicians and surrogates gave their percentage estimate of patient survival on ICU day 3 on a 0-100 probability scale. We defined discordance about prognosis as a difference in the physician's and surrogate's estimates of greater than or equal to ±20%. We used multilevel logistic regression modeling to account for clustering under physicians and patients and adjust for confounders.

Setting: Medical-surgical, trauma, cardiac, and neurologic ICUs of five U.S. academic medical centers located in California, Pennsylvania, Washington, North Carolina, and Massachusetts.

Patients: Two hundred seventy-five patients with acute respiratory distress syndrome at high risk of death or severe functional impairment, their 546 surrogate decision makers, and their 150 physicians.

Interventions: None.

Measurements and main results: There was no predictive utility of surrogates' ratings of the quality of communication about prognosis to identify inaccurate expectations about prognosis (odds ratio, 1.04 ± 0.07; p = 0.54). Surrogates' subjective ratings of the quality of communication about prognosis were high, as assessed with a variety of questions. Discordant prognostic estimates were present in 63.5% (95% CI, 59.0-67.9) of physician-surrogate pairs.

Conclusions: Although most surrogates rate the quality of prognostic communication high, inaccurate expectations about prognosis are common among surrogates. Surrogates' ratings of the quality of prognostic communication do not reliably predict an accurate expectation about prognosis.

Figure 1

Discordance about prognosis is common despite highly rated quality of communication.

Figure 2

Analysis using receiver operator curve shows surrogates' communication quality ratings predict accurate expectations about prognosis no better than chance.

Figure 3

Surrogates who rate quality of communication the highest are also the most optimistic.