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Design and Participants: This secondary sequential content analysis, using previously recorded and transcribed intensive care unit (ICU) family meetings from a prospective, multicenter cohort study (2009-2012), quantified the frequency and investigated the patterns of clinicians’ use of choice frames when discussing preference-sensitive decisions with surrogates. Four coders identified preference-sensitive decision episodes addressed in the meetings, including topics such as mechanical ventilation, renal replacement, and overall goals of care. Prior critical care literature provided specific topics identified as preference sensitive specific to the critical care context. Coders then examined each episode for the types of choice frames used. The choice frames were selected a priori based on decision science literature.
Results: There were 202 episodes across 101 transcripts, with 20% of episodes discussing mechanical ventilation, 19% overall goals of care, 14% renal replacement therapy, 14% postdischarge care (ie, discharge location such as a skilled nursing facility), and the remaining 32% other topics. Clinicians used default framing, in which an option is presented that will be carried out if another option is not actively chosen, more frequently than any other choice frame (63% of episodes). Clinicians presented a polar interrogative (yes/no question to accept/reject a specific care choice) in 21% of episodes. Clinicians more frequently presented options emphasizing both potential losses and gains rather than either in isolation.
Commentary: Effective communication is a carefully honed skill in palliative care. We titrate conversation to the needs of an individual patient and frame choice to effectively elicit goals. This study examines the impact of how clinicians frame choices on outcomes. Clinical teams may feel they are discussing options with patients but are unwittingly encouraging them to choose one option over another. However, the study does not address the emotional component of serious illness communication. While further research should study how to optimize choice framing, there is also a need for training around acknowledging and addressing emotion.
Bottom Line: This study looks at the various ways clinicians frame choices in the ICU. There is a need for broader study in this area to optimize communication interventions.
Reviewer: Kate Lally, MD FAAHPM, Dana-Farber Cancer Institute, Boston, MA
References:
1. Halpern SD, Small DS, Troxel AB, et al. Effect of default options in advance directives on hospital-free days and care choices among seriously ill patients: a randomized clinical trial. JAMA Netw Open. 2020;3:e201742.
2. Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Decis Making. 2015;35:539-557.
3. Mehta SJ, McDonald C, Reitz C, et al. A randomized trial of mailed outreach with behavioral economic interventions to improve liver cancer surveillance. Hepatol Commun. 2024;8:e0349.
Source: Hart JL, Malik L, Li C, et al. Clinicians’ use of choice framing in ICU family meetings. Crit Care Med. 2024;52(10):1533-1542. doi:10.1097/CCM.0000000000006360.
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