title: A multicenter study of key stakeholders' perspectives on communicating with surrogates about prognosis in intensive care units.
abstract: BACKGROUND
  Surrogates of critically ill patients often have inaccurate expectations about prognosis. Yet there is little research on how intensive care unit (ICU) clinicians should discuss prognosis, and existing expert opinion-based recommendations give only general guidance that has not been validated with surrogate decision makers.
  
  
  OBJECTIVE
  To determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness.
  
  
  METHODS
  This was a multicenter study at three academic medical centers in California, Pennsylvania, and Washington. One hundred eighteen key stakeholders completed in-depth semistructured interviews. Participants included 47 surrogates of adult patients with acute respiratory distress syndrome; 45 clinicians working in study ICUs, including physicians, nurses, social workers, and spiritual care providers; and 26 experts in health communication, decision science, ethics, family-centered care, geriatrics, healthcare disparities, palliative care, psychology, psychiatry, and critical care.
  
  
  RESULTS
  There was broad support among surrogates for existing expert recommendations, including truthful prognostic disclosure, emotional support, tailoring the disclosure strategy to each family's needs, and checking for understanding. In addition, stakeholders offered suggestions that add specificity to existing recommendations, including: (1) In addition to conveying prognostic estimates, clinicians should help families "see the prognosis for themselves" by showing families radiographic images and explaining the clinical significance of physical manifestations of severe disease at the bedside. (2) Many physicians did not support using numeric estimates to convey prognosis to families, whereas many surrogates, clinicians from other disciplines, and experts believed numbers could be helpful. (3) Clinicians should conceptualize prognostic communication as an iterative process that begins with a preliminary mention of the possibility of death early in the ICU stay and becomes more detailed as the clinical situation develops. (4) Although prognostic information should be initially disclosed by physicians, other members of the multidisciplinary team-nurses, social workers, and spiritual care providers-should be given explicit role responsibilities to reinforce physicians' prognostications and help families process a poor prognosis emotionally.
  
  
  CONCLUSIONS
  Family members, clinicians, and experts identified specific communication behaviors that clinicians should use to discuss prognosis in the critical care setting. These findings extend existing opinion-based recommendations and should guide interventions to improve communication about prognosis in ICUs.
authors.affiliation: 1 Department of Medicine.
authors.forename: Wendy G
authors.initials: WG
authors.lastname: Anderson
authors.forename: Jenica W
authors.initials: JW
authors.lastname: Cimino
authors.forename: Natalie C
authors.initials: NC
authors.lastname: Ernecoff
authors.forename: Anna
authors.initials: A
authors.lastname: Ungar
authors.forename: Kaitlin J
authors.initials: KJ
authors.lastname: Shotsberger
authors.forename: Laura A
authors.initials: LA
authors.lastname: Pollice
authors.forename: Praewpannarai
authors.initials: P
authors.lastname: Buddadhumaruk
authors.forename: Shannon S
authors.initials: SS
authors.lastname: Carson
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
authors.forename: Catherine L
authors.initials: CL
authors.lastname: Hough
authors.forename: Bernard
authors.initials: B
authors.lastname: Lo
authors.forename: Michael A
authors.initials: MA
authors.lastname: Matthay
authors.forename: Michael W
authors.initials: MW
authors.lastname: Peterson
authors.forename: Jay S
authors.initials: JS
authors.lastname: Steingrub
authors.forename: Douglas B
authors.initials: DB
authors.lastname: White
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D003142:Communication; D003422:Critical Care; D016638:Critical Illness; D003657:Decision Making; D005190:Family; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009726:Nurses; D010820:Physicians; D017410:Practice Guidelines as Topic; D011368:Professional-Family Relations; D011379:Prognosis; D019727:Proxy; D036301:Qualitative Research; D012947:Social Work; D014342:Truth Disclosure
keywords: communication; critical care; prognosis