Assessment of Discordance Between Physicians and Family Members Regarding Prognosis in Patients With Severe Acute Brain Injury

Key Points Question For patients with severe acute brain injury, how prevalent is prognosis discordance between physicians and families, and what factors are associated with it? Findings In this cross-sectional study of 193 patients with severe acute brain injury, prognosis discordance occurred for 61% of patients, with both misunderstanding and belief differences present; prognosis discordance was more likely for family members who were part of minoritized racial groups. Nurses seemed to accurately predict poor family understanding, whereas physicians perceived belief differences as poor family understanding. Meaning 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.
This cross-sectional study uses data from a single neuroscience center to assess for the presence of discordance between physicians and family members regarding prognosis in patients with severe acute brain injury.
Importance Shared decision-making requires key stakeholders to align in perceptions of prognosis and likely treatment outcomes. Objective For patients with severe acute brain injury, the objective of this study was to better understand prognosis discordance between physicians and families by determining prevalence and associated factors. Design, Setting, and Participants This mixed-methods cross-sectional study analyzed a cohort collected from January 4, 2018, to July 22, 2020. This study was conducted in the medical and cardiac intensive care units of a single neuroscience center. Participants included families, physicians, and nurses of patients admitted with severe acute brain injury. Exposures Severe acute brain injury was defined as stroke, traumatic brain injury, or hypoxic ischemic encephalopathy with a Glasgow Coma Scale score less than or equal to 12 points after hospital day 2. Main Outcomes and Measures Prognosis discordance was defined as a 20% or greater difference between family and physician prognosis predictions; misunderstanding was defined as a 20% or greater difference between physician prediction and the family’s estimate of physician prediction; and optimistic belief difference was defined as any difference (>0%) between family prediction and their estimate of physician prediction. Logistic regression was used to identify associations with discordance. Optimistic belief differences were analyzed as a subgroup of prognosis discordance. Results Among 222 enrolled patients, prognostic predictions were available for 193 patients (mean [SD] age, 57 [19] years; 106 men [55%]). Prognosis discordance occurred for 118 patients (61%) and was significantly more common among families who identified with minoritized racial groups compared with White families (odds ratio [OR], 3.14; CI, 1.40-7.07, P = .006); among siblings (OR, 4.93; 95% CI, 1.35-17.93, P = .02) and adult children (OR, 2.43; 95% CI, 1.10-5.37; P = .03) compared with spouses; and when nurses perceived family understanding as poor compared with good (OR, 3.73; 95% CI, 1.88-7.40; P