The Power of Words: The Use of Nudging Language in Neurocritical Care Unit Goals of Care Discussions
Celine Arar1, Winnie Liu1, Michaela Bostwick1, Eleni Panagopoulos1, Joanna Hart2, Miriam Quinlan1, Susanne Muehlschlegel1
1Johns Hopkins School of Medicine, 2Perelman School of Medicine
Objective:
To determine the frequency and patterns of nudging language during goals of care discussions in the neurocritical care unit (NCCU).
Background:
Nudging language refers to subtle phrases, cues, or framing that influences how choices are perceived by listeners. In the NCCU, clinician-led goals of care discussions guide patient surrogates in navigating complex treatment decisions. The use of nudging language in these discussions, which may shape how surrogates decide to initiate, continue, or discontinue life-sustaining treatments, remains unexplored.
Design/Methods:
Fifty-three de-identified transcripts from audio-recorded clinician-family meetings at two different centers, collected from an ongoing multi-center, observational study, were qualitatively analyzed. Unique decision points within each transcript were identified and recorded by two coders (e.g., placement of a tracheostomy or withdrawal of life-sustaining therapy). Next, transcripts were parallel-coded for instances of nudging language using a previously-published framework. Nudges were classified into: salience, framing (further sub-typed as positive, negative, or mixed), options, default, endowment, commission, omission, recommendation, expert opinion, certainty, and social norms. Discrepancies in coding were resolved through discussion.
Results:
Across fifty-three meetings, we identified nudging language in 74% (39/53) of the transcripts. The total number of unique nudges was 202, with a median of 3.5 [3.0-5.0] nudges per transcript. The most common types of nudges were Negative Framing (present in 26/53 family meetings; 49%) e.g. "Most people who go to the nursing home don't survive long there"; Options (26/53 family meetings; 49%) e.g., "We have two pathways"; Recommend (15/53 family meetings; 28%) e.g., "We would recommend not to code him"; and Certainty (9/53 family meetings; 17%) e.g., "He will code within 24-48 hours."
Conclusions:
Preliminary findings suggest that nudging language is very commonly used in NCCU goals of care discussions. Ongoing analysis will examine over 50 additional transcripts to further explore communication patterns and the potential implications for surrogate decision-making.
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