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Predictors of Surrogate Decision Makers Selecting Life-Sustaining Therapy for Severe Acute Brain Injury Patients: An Analysis of US Population Survey Data

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Abstract

Background

Patients with a severe acute brain injury admitted to the intensive care unit often have a poor neurological prognosis. In these situations, a clinician is responsible for conducting a goals-of-care conversation with the patient’s surrogate decision makers. The diversity in thought and background of surrogate decision makers can present challenges during these conversations. For this reason, our study aimed to identify predictive characteristics of US surrogate decision makers’ favoring life-sustaining treatment (LST) over comfort measures only for patients with severe acute brain injury.

Methods

We analyzed data from a cross-sectional survey study that had recruited 1588 subjects from an online probability-based US population sample. Seven hundred and ninety-two subjects had randomly received a hypothetical scenario regarding a relative intubated with severe acute brain injury with a prognosis of severe disability but with the potential to regain some consciousness. Seven hundred and ninety-six subjects had been randomized to a similar scenario in which the relative was projected to remain vegetative. For each scenario, we conducted univariate analyses and binary logistic regressions to determine predictors of LST selection among available respondent characteristics.

Results

15.0% of subjects selected LST for the severe disability scenario compared to 11.4% for the vegetative state scenario (p = 0.07), with those selecting LST in both groups expressing less decisional certainty. For the severe disability scenario, independent predictors of LST included having less than a high school education (adjusted OR = 2.87, 95% CI = 1.23–6.76), concern regarding prognostic accuracy (7.64, 3.61–16.15), and concern regarding the cost of care (4.07, 1.80–9.18). For the vegetative scenario, predictors included the youngest age group (30–44 years, 3.33, 1.02–10.86), male gender (3.26, 1.75–6.06), English as a second language (2.94, 1.09–7.89), Evangelical Protestant (3.72, 1.28–10.84) and Catholic (4.01, 1.72–9.36) affiliations, and low income (< $25 K).

Conclusion

Several demographic and decisional characteristics of US surrogate decision makers predict LST selection for patients with severe brain injury with varying degrees of poor prognosis. Surrogates concerned about the cost of medical care may nevertheless be inclined to select LST, albeit with high levels of decisional uncertainty, for patients projected to have severe disabilities.

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Funding

Dr. Hwang reports other funding from American Brain Foundation, grants from the Neurocritical Care Society, and grants from the Apple Pickers Foundation during the conduct of the study. Dr. Fraenkel reports grants from the Rheumatology Research Foundation and grants from the National Institute of Arthritis and Musculoskeletal and Skin Disease during the conduct of the study (AR060231-06). Dr. White reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study (K24 mentoring award HL148314).

Author information

Author notes

  1. Anisha Garg and Alexandria L. Soto have contributed equally to this manuscript.

Authors and Affiliations

  1. Department of Neurology, Yale School of Medicine, New Haven, CT, USA

    Anisha Garg

  2. Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA

    Alexandria L. Soto, Kevin N. Sheth & David Y. Hwang

  3. Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA

    Andrea K. Knies

  4. Abt Associates, Columbia, MO, USA

    Stanislav Kolenikov

  5. Abt Associates, Chicago, IL, USA

    Marci Schalk

  6. Booz Allen Hamilton, Washington, DC, USA

    Heather Hammer

  7. Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Douglas B. White

  8. Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA

    Robert G. Holloway

  9. Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA

    Kevin N. Sheth & David Y. Hwang

  10. Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA

    Liana Fraenkel

  11. Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA

    Liana Fraenkel

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  1. Anisha Garg
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Contributions

DYH and LF were involved in conceptualization; AKK, DBW, RGH, and KNS were involved in methodology; DYH, SK, and MS contributed to formal analysis and investigation; AG and AS contributed to writing—original draft preparation; AG, ALS, AKK, SK, MS, HH, DBW, RGH, KNS, LF, and DYH contributed to writing—review and editing; DYH, DBW, RGH, KNS, and LF were involved in funding acquisition; DYH, HH, KNS, and LF were involved in resources; and DYH, HH, KNS, and LF were involved in supervision.

Corresponding author

Correspondence to David Y. Hwang.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

This study was approved by the Yale Human Investigation Committee (protocols #1406014207 and #1505015893). Because this is a minimal risk study, participants indicated consent by completing the survey after being presented with an introductory page that included all of the essential components of informed consent.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

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Garg, A., Soto, A.L., Knies, A.K. et al. Predictors of Surrogate Decision Makers Selecting Life-Sustaining Therapy for Severe Acute Brain Injury Patients: An Analysis of US Population Survey Data. Neurocrit Care 35, 468–479 (2021). https://doi.org/10.1007/s12028-021-01200-9

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  • DOI: https://doi.org/10.1007/s12028-021-01200-9

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