Clinicians’ use of choice framing in ICU family meetings

OBJECTIVES: To quantify the frequency and patterns of clinicians’ use of choice frames when discussing preference-sensitive care with surrogate decision-makers in the ICU.

DESIGN: Secondary sequential content analysis.

SETTING: One hundred one audio-recorded and transcribed conferences between surrogates and clinicians of incapacitated, critically ill adults from a prospective, multicenter cohort study.

SUBJECTS: Surrogate decision-makers and clinicians.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: 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 decision episode for the types of choice frames used by clinicians. The choice frames were selected a priori based on decision science literature. In total, there were 202 decision episodes across the 101 transcripts, with 20.3% of the decision episodes discussing mechanical ventilation, 19.3% overall goals of care, 14.4% renal replacement therapy, 14.4% post-discharge care (i.e., discharge location such as a skilled nursing facility), and the remaining 32.1% 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 (127 or 62.9% of decision episodes). Clinicians presented a polar interrogative, or a “yes or no question” to accept or reject a specific care choice, in 43 (21.3%) decision episodes. Clinicians more frequently presented options emphasizing both potential losses and gains rather than either in isolation.

CONCLUSIONS: Clinicians frequently use default framing and polar questions when discussing preference-sensitive choices with surrogate decision-makers, which are known to be powerful nudges. Future work should focus on designing interventions promoting the informed use of these and the other most common choice frames used by practicing clinicians.

University of Pennsylvania
National Heart, Lung, and Blood Institute

Joanna L Hart, Leena Malik, Carrie Li, Amy Summer, Lon Ogunduyile, Jay Steingrub, Bernard Lo, Julian Zlatev, Douglas B White