(651) Shared Decision-Making and Surrogate Prognostic Understanding After Family Meetings in the ICU

Introduction: The care of critically ill patients requires shared decision-making (SDM) with surrogates. SDM is believed to foster mutual understanding of its participants, including understanding of survival prognosis. However, this assumption has not been empirically assessed. We hypothesized that SDM would be significantly associated with improved surrogate understanding of physician prognostic estimates.

Methods: We performed a secondary analysis of data from a trial of a decision support tool for patients receiving prolonged mechanical ventilation (Cox 2019). Family meeting transcripts from the trial were previously coded for 13 SDM clinician behaviors (You 2023). Surveys before and after the family meeting measured physician- and surrogate-estimated patient prognosis (% likelihood of survival at 1 year) and reported their perception of each other’s prognostic estimate. We defined surrogate understanding as the absolute difference between the physician’s prognostic estimate and the surrogate’s perception of this estimate. We compared pre- and post-meeting surrogate understanding with a paired samples t-test. We performed a multivariable regression of SDM score and post-meeting surrogate prognostic understanding, adjusting for conceptually selected confounders (pre-meeting surrogate prognostic understanding, trial intervention group, and surrogate health literacy).

Results: Among the 137 family meetings coded for clinician SDM behaviors, surrogates were an average of 51.9 years (SD 11.8), 75% female (n=102), 78% White (n=107), and 16% Black (n=22). Mean SDM score was 6.3 (SD 2.3). Surrogate understanding of physician prognostic estimate improved by 5.7 points (95% CI 1.8 – 9.6, p = 0.002) after the family meeting. In the multivariable linear regression, SDM score was not associated with surrogate understanding (beta = -0.5, 95% CI -1.7 to 0.6, p = 0.38).

Conclusions: Family meetings in the ICU improved surrogate understanding of physician prognostic estimates. However, increased use of SDM behaviors by clinicians in these meetings were not significantly associated with improved surrogate understanding. Our findings suggest that engaging in SDM does not ensure decision-maker understanding. Future work should examine strategies to improve surrogate understanding of physician prognostic estimates.