Knowing Is (Only) Half the Battle
Although a high quality medical decision has no universally accepted definition (1) most would agree that, at a minimum, it reflects a choice that is medically feasible and intended to promote the values of the patient. Yet in the context of critical illness, meeting even this minimum standard is challenging because patients are often incapacitated, their prognoses are uncertain, and the decisions required are emotionally charged and highly consequential. Prevailing wisdom and professional society guidelines (2) suggest that a process oriented benchmark for which to strive is deliberative shared decision making that promotes patient goals. However, we lack evidence on the utility or sufficiency of this process and how best to promote it. Perhaps as a result we see many undesirable outcomes of critical care: potentially inappropriate care and unwanted debility for patients, stress and depression among surrogates, and high rates of burnout among clinicians (3) Such adverse consequences have spawned great interest in using aids to improve decision quality. Indeed, decision aids have been shown to enhance patient knowledge related to a given decision (4) However, the promise of decision aids rests on the assumption that mitigating knowledge deficits is the lynchpin to improving decision qualityan assumption that is largely untested, particularly when applied to surrogate decision makers for critically ill patients. In their article, Cox and colleagues (5) examine whether a surrogate facing decision aid improves cliniciansurrogate concordance on estimates of 1 year survival or any of several patient and surrogate outcomes for patients receiving prolonged mechanical ventilation >10 days) They find that it generates no such benefits. But thanks to several strengths in the study design and reporting, the authors shed new light on the unique challenges of shared decision making with surrogates. The authors recruited 416 surrogates and 427 physicians and nurses involved in the care of 277 patients receiving prolonged mechanical ventilation in 13 medical and surgical intensive care units. Fidelity to the intervention and protocol were high: More than 90% of surrogates in the intervention group completed the decision aid, and more than 90% of surrogates in both groups participated in clinician led family meetings. Although surrogates who completed the decision aid showed better understanding of the clinician's predictions and had less decisional conflict, theylike their counterparts in the control groupmaintained expectations for their loved ones' survival that were dramatically more optimistic than those of clinicians or an evidence based clinical prediction model. In addition, the decision aid did not improve surrogates' psychological outcomes 3 or 6 months later and did not affect patient survival, hospital length of stay, or duration of mechanical ventilation. As Cox and colleagues note, these findings suggest that surrogates' overoptimism, and the resultant patient and surrogate outcomes, may stem more from beliefs than knowledge. Such formative beliefs may regard the patient's unique characteristics, the power of positivity, and the role of surrogates in making decisions. Whether and how these beliefs are mutable may represent the true lynchpin to aligning expectations and enhancing the quality of surrogate decision making. A particularly innovative feature of the authors' decision aid demonstrates this point well. On the basis of information about the patient's values provided by the surrogate, an algorithm predicted the patient's preferred goal of treatment: maximizing comfort, a time limited trial of restorative care, or maximizing survival. Although this prediction stemmed from the surrogate's own assessment of the patient's values, surrogates rejected it 47% of the time and in such cases almost uniformly opted for a goal focused more on survival than comfort. Although the algorithm's predictions could have been flaweda fact that could only be adjudicated by the patients themselvessurrogates' propensities to override these predictions in a nearly unidirectional manner speaks volumes about how they process information provided by clinicians and construct their own preferences. Why they felt compelled to override such predictions, which was unfortunately not explored in this study, may illuminate the path toward improving decision quality. Although studies have shown that seriously ill patients often prefer function over longevity (6) and rate certain states of debility as worse than death (7) surrogates may struggle to acknowledge such values. If so, decision aids that provide more information and encourage greater deliberation may be insufficient. Indeed, the value of deliberation in clinical decision making is itself unsubstantiated. Inducing deliberation rather than allowing intuitive judgments often leads to lower quality decisions (8) and may serve primarily to increase the decision maker's confidence in the decision, a form of confirmation bias (9) We have recently shown that encouraging intuitive rather than deliberative decision making leads seriously ill patients to make choices that are equally or more closely aligned with their values (10) Thus, although we agree with Cox and colleagues that surrogates' emotions may have blunted the effect of the decision aid, we also posit that interventions that merely enhance knowledge and induce deliberation may never promote better surrogate decision making. What may work better? Future research will be needed to answer this question. However, informed by insights from this meticulously conducted trial, we might predict that had clinicians reviewed surrogates' responses with them, they may have been able to access surrogates' beliefs, attend to their emotions, and unpack their overly optimistic expectations and the sources of their ensuing preferences. Doing so may have helped lift the burdens of shared decision making for incapacitated patients from the shoulders of the surrogates alone. If so, then perhaps rigorously developed decision aids, such as that used in this trial, may be a useful adjunct in a process whereby clinicians help surrogates interpret and apply their knowledge of patients' values to the decisions at hand. Knowing may indeed be half the battle, but future work that goes beyond decision aids will be needed to truly improve preference sensitive decision making.
Annals of Internal Medicine