Prognostication of patients in coma after cardiac arrest: Public perspectives

Til, Janine Astrid van; Bouwers-Beens, Eline; Mertens, Mayli; Boenink, Marianne; Groothuis-Oudshoorn, Catharina Gerarda Maria; Hofmeijer, Jeannette

doi:10.1016/j.resuscitation.2021.10.002

Cited by 7 publications

(3 citation statements)

References 26 publications

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“…For some families, these conversations may center on the importance of proper communication of the level of prognostic certainty in likelihood of recovery of behavioral consciousness so that families can accurately assess the value of maintaining a potential state of nonbehavioral phenomenal consciousness. [32][33][34] Given the high degree of prognostic uncertainty in the field of disorders of consciousness, some may feel that even a small chance at recovering behavioral consciousness may justify continuing life-sustaining treatment for a period. 1,14 By eliciting and acknowledging the individualized beliefs, values, and goals that might importantly bear on such treatment preferences, clinicians have the opportunity to cultivate trustworthy relationships by inviting caregivers into the diagnostic and prognostic process, highlighting how potential endpoints might align with or conflict with individual patient goals, and providing multidisciplinary, longitudinal support that affords families the time to navigate a complex decision-making process and revisit goals of care discussions as needed.…”

Section: Conversations About Diagnosismentioning

confidence: 99%

Disambiguating Consciousness in Clinical Settings

Choi,

Young

2023

Neurology

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Patients affected by severe brain injury can experience complex states of disordered consciousness. These include the comatose state, characterized by a complete loss of spontaneous or stimulus-induced wakefulness and awareness; the vegetative state/unresponsive wakefulness syndrome, in which patients can be awake but exhibit no signs of conscious perception or deliberate action; the minimally conscious state, characterized by low-level awareness of self or environment; and the acute confusional state, which entails the recovery of wakefulness and awareness with persistent confusion.1,2 Patients with acute brain injuries may move unpredictably between these states and often evade precise and accurate assessment due to limitations in assessment techniques and patient-specific factors masking expression of consciousness.3

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Section: Conversations About Diagnosismentioning

confidence: 99%

Disambiguating Consciousness in Clinical Settings

Choi,

Young

2023

Neurology

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“…34 Subjective clinician judgment is essential because there are no gold standard prediction algorithms with acceptable error rates. [35][36][37][38] Recognizing that gap, most society guidelines and scientific summaries recommend multimodal outcome prognostication. 39 However, even broadly informed approaches leave many patients with indeterminate prognoses, 37,38,[40][41][42] reflecting the limits to such models.…”

Section: Clinician Decision Making Analysismentioning

confidence: 99%

Cognitive Biases and Shared Decision Making in Acute Brain Injury

Steinberg,

Fischhoff

2023

Semin Neurol

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Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.

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“…For instance, Peay and colleagues asked participants to rate their preferences regarding participating in treatment decisions with options ranging from “I prefer to make the decision about which treatment I will receive” to “I prefer to leave all decisions regarding treatment to my doctor” [ 10 , 39 ]. Some studies also assess preferences for the role of others in the decision (such as family and caregivers), to understand the interactions within the patient–caregiver–clinician triad [ 40 ].…”

Section: Recommendation 2 Considering Role Preferences In Meaningful ...mentioning

confidence: 99%

Role Preferences in Medical Decision Making: Relevance and Implications for Health Preference Research

van Til,

Pearce,

Ozdemir

et al. 2023

Patient

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Health preference research (HPR) is being increasingly conducted to better understand patient preferences for medical decisions. However, patients vary in their desire to play an active role in medical decisions. Until now, few studies have considered patients’ preferred roles in decision making. In this opinion paper, we advocate for HPR researchers to assess and account for role preferences in their studies, to increase the relevance of their work for medical and shared decision making. We provide recommendations on how role preferences can be elicited and integrated with health preferences: (1) in formative research prior to a health preference study that aims to inform medical decisions or decision makers, (2a) in the development of health preference instruments, for instance by incorporating a role preference instrument and (2b) by clarifying the respondent’s role in the decision prior to the preference elicitation task or by including role preferences as an attribute in the task itself, and (3) in statistical analysis by including random parameters or latent classes to raise awareness of heterogeneity in role preferences and how it relates to health preferences. Finally, we suggest redefining the decision process as a model that integrates the role and health preferences of the different parties that are involved. We believe that the field of HPR would benefit from learning more about the extent to which role preferences relate to health preferences, within the context of medical and shared decision making.

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Prognostication of patients in coma after cardiac arrest: Public perspectives

Cited by 7 publications

References 26 publications

Disambiguating Consciousness in Clinical Settings

Disambiguating Consciousness in Clinical Settings

Cognitive Biases and Shared Decision Making in Acute Brain Injury

Role Preferences in Medical Decision Making: Relevance and Implications for Health Preference Research

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