Clinicians and researchers are calling for a paradigm shift.
In neuro ICUs, where patients are often unconscious, family members and physicians are tasked with making time-critical care decisions on their behalf. Yet families and doctors often have very different beliefs on whether the patient will recover from brain injury, which may affect such decisions. In fact, one recent study on severe acute brain injury patients found that physicians and families don’t align on the patient’s ability to recover more than half the time.
The same study noted one way to bridge this “prognosis discordance” is to strengthen the role of the bedside nurse in those prognosis and care discussions. Here’s why:
Severe Acute Brain Injury: How Prevalent Is Prognosis Discordance?
The cross-sectional study, published in Critical Care Medicine by Kiker et al., included 193 patients diagnosed with severe acute brain injury in the medical and cardiac intensive care units of a single neuroscience center.
From January 2018 to July 2020, researchers surveyed physicians, nurses and families of severe brain injury patients, who had experienced stroke, traumatic brain injury or hypoxic ischemic encephalopathy, and had a Glasgow Coma Scale score less than or equal to 12.
Family members were asked to predict the likelihood that the patient would regain independence, how the physician would answer the same question and how much they would trust the information received from the physician.
Likewise, physicians were also asked to predict the patient’s recovery from brain injury. In addition, physicians and bedside nurses were asked to rate the quality of the family’s understanding of the patient’s brain injury prognosis.
Kiker et al. identified three types of differences in their responses on severe brain injury prognosis:
- Prognostic discordance: when there was 20% or greater difference between family and physician prognosis predictions
- Misunderstanding: when there was 20% or greater difference between physician prediction and the family’s estimate of physician prediction
- Optimistic belief difference: when there was any difference between family prediction and their estimate of physician prediction
After 30 months of surveys, the study authors found that there was prognosis discordance in 61% of the severe acute brain injury cases, misunderstanding in 46% of cases and optimistic belief difference in 54%.
Acute Brain Injury Prognosis: Optimism vs. Misunderstanding
Kiker et al. theorized that surrogates have different predictions about recovery from brain injury either because 1.) Families intentionally chose a more optimistic outcome despite clinician information or 2.) There is a misunderstanding of clinical information.
In the Kiker et al. study, attending physicians were more likely to misinterpret family members’ optimism as a misunderstanding of the likelihood of recovery from brain injury. Meanwhile nurses were able to more accurately identify misunderstandings between a physician and the patient’s surrogates. The authors suggest that bedside nurses could therefore be critical in facilitating improved communication in these instances.
“It suggests [that] inclusion of bedside nurses in both understanding the family’s perceptions but also perhaps in the actual decision-making process may help,” Dr. Christopher C. Giza, a fellow of the American Academy of Neurology and professor of pediatric neurology and neurosurgery at UCLA in Los Angeles, told Medscape about the Kiker et al. study.
Yet bedside nurses are not always part of the discussions between physician and the patient’s loved ones. In a study of published literature regarding nurses’ perceptions and experiences with diagnosis and prognosis-related communication, nurses cited specific barriers that they believe prevent them from a central roles in crucial conversations.
Cited factors included lack of experience or training, discomfort, lack of role definition, fears of taking way hope, and lack of time. There are also nurse-physician factors such as perceived exclusion and how information is conveyed.
Aligning on Severe Brain Injury Prognosis: The Way Forward
Prognosis discussions in the neuro ICU are rife with uncertainty and go beyond survival to whether
the acute brain injury patient will achieve functional recovery and have quality of life. These discussions and care decisions became all the more challenging during COVID-19 visitor restrictions: Neurocritical care staff observed an even wider gap between prognosis predictions and family members’ understanding when they could not be bedside to witness the extent of the brain injury firsthand.
While Kiker et al. were able to show how prevalent prognosis discordance is with patients with severe brain injury as well as characterize the types of misunderstandings, future research is needed to solidify practical steps for better alignment and whether this has any effect on patient outcomes.