DISCUSSION
Our project shows a survey-based approach to investigate concordance in
perceptions of communication among participants in family discussions
and identify domains of communication in a Neurocritical care setting.
Most participants in our cohort felt that treatment options were
adequately conveyed and were satisfied with the communication, although
the impact on healthcare decisions was reported lower than expected.
Possible reasons could have been include preexisting religious beliefs,
or prior plan of care discussion.
Education was the most frequently mentioned domain of communication in
open-ended questions among all groups. Engagement and enlistment were
not frequently mentioned by families. Remarks from families and the
observer noted empathy which was notably absent in provider remarks.
These findings led us to create an education module implemented as a
part of our curriculum highlighting ways to improve communication. Given
the extremely positive results of the pre-module surveys, post-module
assessment was not felt to provide contributory information to boost
initiatives to improve communication.
Our limitations included small sample size, restriction to
English-speaking participants, inability to rule out selection bias or
Hawthorne effect among respondents and high degree of competency
presumed from attending physicians directing most conversations. It is
possible that families with discomfort or conflict during these
discussions refused consent for the study creating self-selection of
satisfied respondents. Furthermore, conversations in family lounge areas
mentioning the study may have affected expectations of family
satisfaction and concordance.
This study did not assess other factors that influence patient
decision-making (e.g. family religiosity, educational level of
decision-makers, socioeconomic status). Such factors may underlie
discordant provider and family perceptions of how provider
communications influenced family decision-making.
Traditional summary measures of agreement like Krippendorf’s or
Cronbach’s alpha, and intra-class coefficients were also considered.
Krippendorf’s alpha calculated on the original data showed poor to
moderate agreement beyond chance; the discrepancy between a high percent
agreement and low Krippendorf’s alpha may indicate that the method
performs best with responses that are more diverse.
Overall, our study showed high satisfaction among providers, families,
and the observer regarding quality of communication during family
discussions in the Neurocritical care unit.
Our study identified the variability in perceptions amongst various
domains of communication. This was useful for designing and testing
educational interventions involving family communication.