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Christina Pesonen, APRN, CNPJames H. Lantry III, MD
08/15/2024
This Concise Critical Appraisal explores a study that reviewed transcripts from family meetings in the ICU to determine how clinicians use choice frames to present care options.
The intensive care unit (ICU) is filled with preference-sensitive decision-making for patients or their surrogate decision-makers. These decisions are ideally guided by the patient’s values; however, the circumstances surrounding these decisions are often complex, stressful, and constrained by time. Clinicians are faced with expeditiously establishing trust and making shared decisions that align with the patient’s values. Choice framing strategies can help clinicians provide a context for communicating care options.
Previous evidence has suggested that choice framing affects how decisions are made; however, clinicians’ use of specific choice frames had not been quantified.1-4 A recent study by Hart et al examined ICU family meeting transcripts from a multicenter study conducted from 2009 to 2012.1,5 A secondary analysis was completed on 101 of these transcripts with the primary objective of quantifying clinician use of specific choice frames and identifying patterns. Decision episodes were determined when discussion involved the initiation, continuation, or discontinuation of an intervention. After the decision episodes were identified, the choice frames used by the clinicians were determined with an agreed-upon codebook that defined specific choice frames.
The results identified 202 decision episodes throughout the 101 transcripts. Clinicians used the default choice frame most frequently (62.9% of decision episodes). The default choice frame is an option presented that will be chosen if an alternative is not chosen. Clinicians used the polar interrogative choice frame in 21.3% of decision episodes. The polar interrogative choice frame presents an option as an explicit yes or no.
Hart et al discussed how the use of default and polar interrogative choice framing in preference-sensitive decisions can lead to harmful bias.1 These two choice frames suggest that there are no other options or that the clinician is recommending the option. Surrogates must make decisions that align with patient values; however, clinicians do not always present decisions in a manner that leads to an unbiased decision.
Preference-sensitive decision-making in the ICU with surrogates requires complex communication and can be difficult for clinicians to present in an unbiased manner. Certain choice frames, such as the default frame, have a place in these discussions but may also introduce bias and obscure reasonable options. There is a need to further explore choice frames to provide support for surrogates and mitigate harmful bias.
Each institution must determine how best to use choice framing to facilitate communication that allows surrogates to make decisions that align with patient values. Each institution must also determine how to train clinicians to improve communication in preference-sensitive care. Future research must focus on how to train primary care clinicians to start preference-sensitive care discussions with patients and their surrogates to optimize decisions in a non-ICU environment.
References
Hart JL, Malik L, Li C, et al. Clinicians’ use of choice framing in ICU family meetings. Crit Care Med. 2024 Jun 24. Online ahead of print.
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 Mar 2;3(3):e201742.
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 May;35(4):539-557.
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. 2023 Dec 15;8(1):e0349.
White DB, Carson S, Anderson W, et al. A multicenter study of the causes and consequences of optimistic expectations about prognosis by surrogate decision-makers in ICUs. Crit Care Med. 2019 Sep;47(9):1184-1193.
Author
Christina Pesonen, APRN, CNP
Christina Pesonen, APRN, CNP, is a student in the acute care nurse practitioner certification program at the University of Minnesota.
Author
James H. Lantry III, MD
James H. Lantry III, MD, is the associate director of quality and critical care at Inova Fairfax Hospital and an adjunct assistant professor of medicine and critical care medicine at the University of Maryland School of Medicine in Baltimore, Maryland, USA. Dr. Lantry is an editor of Concise Critical Appraisal.
