Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study

Background and Objectives: There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition).

Methods: We conducted a multi-center cross-sectional mixed-methods study analyzing de-identified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from seven U.S. centers. Two coders assigned prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., "80% survive"; "She'll probably survive") or non-probabilistic (characterizing outcomes without offering likelihood; e.g., "She may not survive"). We applied univariate and multivariable binomial logistic regression to examine independent associations between prognostic language and domain of prognosis.

Results: We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [IQR 0;2]), physical function (median 2[IQR 0;7]), cognition (median 2[IQR 0;6]) and overall recovery (median 2[IQR 1;4]). Most statements were non-probabilistic (316/512 [62%]), 10/512(2%) of prognostic statements offered numeric estimates, and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared to statements about cognition, statements about survival (OR 2.50[95% CI 1.01, 6.18]; p=0.048) and physical function (OR 3.22[1.77, 5.86]; p<0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34 [95% CI 0.17-0.66]; p=0.002).

Discussion: Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness.