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

  
By Anisha Garg, Alexandria L. Soto, Andrea K. Knies, Stanislav Kolenikov, Marci Schalk, Heather Hammer, Douglas B. White, Robert G. Holloway, Kevin N. Sheth, Liana Fraenkel & David Y. Hwang
First Online: 23 February 2021

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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