In CINPs, families must consider the patients’ potential for long-term physical and cognitive disability when contemplating WOLST decisions ( 10– 12) and therefore routinely turn to clinicians to provide them with a prognosis. Empirical research in general critical care has confirmed a substantial variability in how clinicians disclose prognosis and treatment recommendations to families ( 8, 9). While patient and family characteristics, including race, socioeconomic factors, geographic location, religiosity, and personal values, may partly be responsible for this variability ( 6, 7), breakdowns in clinician-family communication may also pose a potential explanation. Several studies in CINPs have documented an alarming variability of WOLST rates between centers, ranging from 0% to 96% in stroke, and 45–87% in severe traumatic brain injury, even after adjusting for disease severity and patient’s age ( 4, 5). The vast majority, of critically ill neurologic patients (CINPs), upwards of four in five, die after withdrawal-of-life-sustaining treatments (WOLST) by family members acting as surrogate decision-makers ( 1– 3). Prognostication approach was not independently associated with WOLST ( p = 0.198). WOLST was more likely in older patients ( p = 0.059) and with more experienced clinicians ( p = 0.07). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). After adjustment, only clinician specialty independently predicted prognostication approach ( p = 0.027). Before adjustment, prognostication approach was associated with center ( p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists p = 0.001), patient age ( p = 0.08), diagnosis ( p = 0.059), and meeting length ( p = 0.03). Clinicians used four distinct prognostication approaches: Authoritative (21% recommending treatments without discussing values and preferences) Informational (23% disclosing just the prognosis without further discussions) advisory (42% disclosing prognosis followed by discussion of values and preferences) and responsive (14% eliciting values and preferences, then disclosing prognosis).
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