Communication of Risk and Benefit*

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In a 2013 piece in “The New Yorker,” cardiologist Lisa Rosenbaum described a conversation she had with one of her cardiomyopathy patients and his wife (1). Dr. Rosenbaum was recommending to her patient that he receive an implantable cardiac defibrillator as research had shown that these devices save lives in patients with cardiomyopathy. As she described the risks involved with such a device, the patient’s wife interjected to ask what would happen if the device shocked her husband when it was not supposed to. The wife was concerned about the possibility of an inappropriate shock. Dr. Rosenbaum thought to herself how different the conversation would have been had she started with the question, “Would you rather die or experience an inappropriate shock?”
The conversation that Dr. Rosenbaum had with her patient and his wife illustrates what is known in psychology as the “affect heuristic,” which describes the role that emotions play in our perceptions of benefits and risks. Under the affect heuristic, the manner in which information about benefits is presented can impact people’s perceptions of risk (and vice versa) (2). In the case above, the emotional response to the presentation of risk may lead to an incorrect inference of little benefit of the procedure.
In this issue of Pediatric Critical Care Medicine, Hebert et al (3) present a retrospective review of audio-recorded family-physician conferences regarding tracheostomy placement in children and survey an expert panel of clinicians to generate a list of recommended benefits and risks for comparison. The study design provides for an interesting characterization of what practitioners actually say to families and not necessarily what they perceive they have said after the fact. Exposing conscious and subconscious biases in a quantifiable fashion is an important step in optimizing communications with patients and their families.
The authors report that the median length of time from admission to the PICU to the family conference to discuss tracheostomy was 14 days. As the authors acknowledge, there is a high likelihood that other less formal discussions between caregivers and families preceded the family conference though were not captured. There is significant debate and practice variation among providers as to when to advocate for tracheostomy. Holloway et al (4) found in a single-center report that for each pretracheostomy ventilator day, total hospital length of stay increased by 1.9 days. Furthermore, Holloway et al (4) suggests that a cutoff of 14 days best delineated early from late tracheostomy, with the late group subject to significantly longer posttracheostomy hospital lengths of stay. Given that the common benefit cited by physicians was that tracheostomy would lead to a faster discharge from the PICU, attention to the timing of the initiation of discussions, either formal or informal, is important.
The theme of nonpermanence of tracheostomy was identified as a benefit commonly presented to families during conferences. The indication for tracheostomy may confound discussions of this benefit. Children with neurologic or neuromuscular conditions requiring tracheostomy for chronic mechanical ventilation, for example, may never be appropriate for decannulation.
Among children with the potential for decannulation, it is often difficult to prognosticate for families on the probability of, or time horizon to, decannulation. Experimental evidence suggests that when individuals are presented information regarding the benefits of an uncertain situation, they are more sensitive to the “possibility” rather than the “probability” of the positive consequence, in this case, decannulation (5). This sensitivity furthers supports the expert clinician panel’s recommendations for a balanced approach by equally weighing risks and benefits.

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