Psychological Attachment Orientations of Surrogate Decision-Makers and Goals-of-Care Decisions for Brain Injury Patients in ICUs.

Publisher: Wolters Kluwer Health Country of Publication: United States NLM ID: 101746347 Publication Model: eCollection Cited Medium: Internet ISSN: 2639-8028 (Electronic) Linking ISSN: 26398028 NLM ISO Abbreviation: Crit Care Explor Subsets: PubMed not MEDLINE

Original Publication: Philadelphia, PA : Wolters Kluwer Health, [2019]-

To determine whether ICU surrogates with "insecure" psychologic attachment orientations are more prone to requesting tracheostomy and gastrostomy (i.e., life-sustaining therapy) for severe acute brain injury patients with poor prognosis compared to surrogates with "secure" orientations.
Design: Cross-sectional survey from November 2017 to August 2018.
Setting: Single neuroscience ICU at an academic medical center.
Subjects: Consecutive sample of surrogates of patients admitted to the ICU with a minimum length of stay of 24 hours.
Interventions: None.
Measurements and Main Results: We identified surrogates' psychologic attachment orientation via a standard tool, the Relationship Questionnaire, and collected other surrogate and patient demographics. We also presented surrogates with a hypothetical scenario of an intubated severe acute brain injury patient with poor prognosis and asked each surrogate whether he or she would request life-sustaining therapy or comfort measures only. Fisher exact test was used to compare frequency of life-sustaining therapy selection between secure and insecure surrogates. Additionally, we conducted univariate and multivariate analyses to determine other independent predictors of life-sustaining therapy selection. Two-hundred seventy-five of 713 (38.6%) eligible respondents participated; 153 (55.6%) surrogates were secure, and 122 (44.4%) insecure. There was no significant difference in the proportion of secure respondents selecting life-sustaining therapy compared to insecure (18.3% vs 20.5%; p = 0.38). Although still nonsignificant, the observed difference was slightly greater for those with a specific "anxious" insecure subtype versus "nonanxious" (18.2% vs 23.0%; p = 0.41). Overall, a higher proportion of respondents selecting life-sustaining therapy (vs comfort measures only) reported feeling uncertain or very uncertain about the hypothetical decision (45.3% vs 9.5%; p < 0.001). In a multivariate model, nonwhite race and high religiosity were significant predictors of life-sustaining therapy selection.
Conclusions: Although surrogate attachment orientation is not predictive of life-sustaining therapy selection, nonwhite race and high religiosity are. Future interventions designed to support severe acute brain injury surrogates could focus on surrogates prone to selecting life-sustaining therapy with high degrees of uncertainty.
Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest.
(Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Psychooncology. 2007 Dec;16(12):1080-91. (PMID: 17464942)
Psychiatry Res. 2013 Dec 30;210(3):919-24. (PMID: 24075307)
J Am Geriatr Soc. 2002 Feb;50(2):378-81. (PMID: 12028224)
Gerontology. 2006;52(2):111-23. (PMID: 16508319)
Am J Respir Crit Care Med. 2016 Jan 15;193(2):154-62. (PMID: 26378963)
Psychooncology. 2009 Sep;18(9):927-35. (PMID: 19140124)
Attach Hum Dev. 2009 May;11(3):223-63. (PMID: 19455453)
JAMA. 2009 Mar 18;301(11):1140-7. (PMID: 19293414)
Clin Psychol Rev. 2010 Mar;30(2):259-68. (PMID: 20034720)
J Psychosom Res. 2019 Jan;116:93-99. (PMID: 30655000)
Psychooncology. 2012 Sep;21(9):935-43. (PMID: 21544898)
Ann Intern Med. 2019 Mar 5;170(5):285-297. (PMID: 30690645)
Crit Care Med. 2011 Jul;39(7):1663-9. (PMID: 21460710)
J Sex Med. 2015 Sep;12(9):1953-60. (PMID: 26346525)
J Clin Oncol. 2007 Feb 10;25(5):555-60. (PMID: 17290065)
J Pers Soc Psychol. 1997 Nov;73(5):1092-106. (PMID: 9364763)
Behav Res Methods. 2009 Nov;41(4):1149-60. (PMID: 19897823)
Neurocrit Care. 2015 Aug;23(1):131-41. (PMID: 25990137)
Ann Intern Med. 1998 Apr 15;128(8):621-9. (PMID: 9537935)
Neurocrit Care. 2017 Oct;27(2):154-162. (PMID: 28685395)
Crit Care Med. 2001 Sep;29(9):1792-7. (PMID: 11546988)
J Crit Care. 2015 Apr;30(2):231-5. (PMID: 25480457)
Psychooncology. 2006 May;15(5):431-44. (PMID: 16155969)
J Pain Symptom Manage. 2020 Feb;59(2):261-269. (PMID: 31539603)
Pain. 2006 Jul;123(1-2):146-54. (PMID: 16644132)
Ethn Dis. 2001 Winter;11(1):97-106. (PMID: 11289258)
Palliat Support Care. 2010 Jun;8(2):227-33. (PMID: 20307372)
J Gen Intern Med. 2012 Dec;27(12):1657-65. (PMID: 23011253)
Hastings Cent Rep. 2010 Sep-Oct;40(5):36-45. (PMID: 20964162)
Arch Intern Med. 1995 Oct 23;155(19):2056-62. (PMID: 7575064)
Soc Sci Med. 2006 Dec;63(12):3067-79. (PMID: 16997440)
Ann Intern Med. 2012 Mar 6;156(5):I26. (PMID: 22393146)
J Nerv Ment Dis. 2010 Dec;198(12):881-4. (PMID: 21135639)
Contemp Clin Trials. 2012 Nov;33(6):1245-54. (PMID: 22772089)
Neurology. 2020 May 12;94(19):e2054-e2068. (PMID: 32341190)
J Am Geriatr Soc. 1995 Feb;43(2):113-21. (PMID: 7836634)
J Gen Intern Med. 1993 Jul;8(7):361-8. (PMID: 8410396)
Crit Care Med. 2014 Feb;42(2):265-71. (PMID: 24105452)
Death Stud. 2005 May;29(4):277-99. (PMID: 15849880)
Int J Law Psychiatry. 2006 Jan-Feb;29(1):48-56. (PMID: 16289754)
JAMA. 1995 Dec 13;274(22):1775-9. (PMID: 7500508)
Health Psychol. 2011 Nov;30(6):814-8. (PMID: 22081941)
N Engl J Med. 1990 Feb 1;322(5):309-15. (PMID: 2296273)
J Behav Med. 2013 Feb;36(1):51-60. (PMID: 22311104)
Palliat Support Care. 2005 Jun;3(2):131-42. (PMID: 16594438)
Behav Res Methods. 2007 May;39(2):175-91. (PMID: 17695343)
Am J Hosp Palliat Care. 2015 Dec;32(8):855-60. (PMID: 25155029)
J Psychol. 2016 Nov 16;150(8):931-948. (PMID: 27603938)
N Engl J Med. 2018 Jun 21;378(25):2365-2375. (PMID: 29791247)
Psychol Rep. 2000 Oct;87(2):643-8. (PMID: 11086617)
Health Psychol. 2015 Mar;34(3):262-9. (PMID: 25110853)
J Pers Soc Psychol. 1991 Aug;61(2):226-44. (PMID: 1920064)
PLoS One. 2019 Sep 26;14(9):e0216507. (PMID: 31557186)
Psychosomatics. 2004 Mar-Apr;45(2):119-28. (PMID: 15016925)
Arch Intern Med. 2006 Mar 13;166(5):493-7. (PMID: 16534034)
Pers Soc Psychol Rev. 2014 Nov;18(4):326-48. (PMID: 24727975)

UL1 TR001863 United States TR NCATS NIH HHS

Keywords: critically ill; end-of-life care; goals of care; intensive care; palliative care medicine; terminal care

Date Created: 20200723 Latest Revision: 20220415

20221213

PMC7340333

10.1097/CCE.0000000000000151

32696015