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EC-ALI: Identifying Effective Strategies to Disclose Prognosis

PI: Douglas B. White, MD, MAS, Director, Program on Ethics and Decision Making

Co-Investigators: Wendy Anderson, MD, MS; Bernard Lo, MD, MA ; Michael Matthay, MD; Garrett Bird, MD, CM; Michael Peterson, MD; Shannon Carson, MD;  Jay Steingrub, MD; Paul Jodka, MD; Catherine L. Hough, MD; J. Randall Curtis, MD, MPH

Funding: NIH R01HL094553 Project period (9/30/09 to 6/30/13)

Project Overview

This is a multi-center, prospective cohort study using both quantitative and qualitative methods to identify effective, acceptable strategies to disclose prognostic information to surrogate decision-makers of patients with acute lung injury (ALI) at high risk of death or severe functional impairment. This study has two parts.  The main study is focused on audiotaping physician-family conferences and eliciting quantitative prognostic estimates by physicians and surrogates participating in these conferences, and then examining what disclosure strategies predict family comprehension.  The second part is a nested sub-study employing semi-structured interviews of surrogates and physicians who participated in the main study.  Additionally, we will conduct semi-structured interviews with other providers who care for ICU patients (i.e., nurses, social workers, spiritual care providers) and national experts in the fields of critical care, ethics, communication, palliative care, prognostication, and bereavement.

Aim 1

To determine what disclosure strategies predict accurate understanding of prognosis by surrogates, we will audiotape physician-surrogate conferences in which prognosis is discussed, obtain physicians’ and surrogates’ prognostic estimates after these conferences, and systematically analyze the transcribed conferences using reliable methods developed by our group.  We will use multivariate analytic techniques to determine the association between specific disclosure techniques and surrogates’ comprehension of prognosis.

Aim 2

To determine if surrogates’ misperceptions about prognosis are associated with clinical outcomes, we will assess quality of communication (as assessed by the surrogate) and decisional conflict (both physician-surrogate conflict and internal conflict of the surrogate). We will use multivariate analysis to determine whether poor comprehension of prognosis is an independent predictor of these important patient and process outcomes.

Aim 3

To determine physicians’, surrogates’, providers’, and national experts’ perceptions about how to effectively and sensitively communicate a poor prognosis, and to identify barriers to implementing these strategies into clinical practice.