Background: Hospitalists frequently lead family meetings with patients and family members. Shared decision making employed during family meetings is believed to foster mutual understanding of its participants, including understanding of prognosis. However, this assumption has not been empirically assessed.

Methods: We performed a secondary analysis of data from a trial of a decision support tool for patients receiving prolonged mechanical ventilation (Cox 2019). Family meeting transcripts from the trial were previously coded for 13 SDM clinician behaviors (You 2023) and a summative SDM score was calculated for each meeting. Surveys before and after the family meeting were administered in which physicians and surrogates estimated patient prognosis (percent likelihood of survival at 1 year) and reported their perception of each other’s prognostic estimate. We defined surrogate misunderstanding as the absolute difference between the surrogate’s perception of the physician’s prognostic estimate and the physician’s prognostic estimate. We compared pre- and post-meeting surrogate misunderstanding with a Wilcox signed rank test. To assess the association of SDM and surrogate misunderstanding, we performed a linear regression of SDM score and post-meeting surrogate prognostic misunderstanding, adjusting for conceptually selected confounders (pre-meeting surrogate prognostic misunderstanding, trial arm, and surrogate health literacy).

Results: Among the 137 family meetings coded for clinician SDM behaviors, surrogates were an average of 52 years (SD 12), 74% female (n=102), 78% White (n=107), and 16% Black (n=22). Mean SDM score was 6 (IQR 4-9). There was a statistically significant decline in surrogate misunderstanding of physician prognostic estimate after the family meeting (median pre-meeting surrogate misunderstanding 22%, IQR = 10-40; median post-meeting surrogate misunderstanding 15%, IQR = 5-34; p = 0.002). In the multivariable linear regression, SDM score was not significantly associated with surrogate misunderstanding ( = -0.76, 95% CI -1.85 to 0.33, p = 0.17).

Conclusions: Family meetings improved surrogate misunderstanding of physician prognostic estimates. However, increased use of SDM behaviors by physicians in these meetings were not significantly associated with improved surrogate misunderstanding. Our findings suggest that engaging in SDM does not ensure decision-maker understanding. Future work should examine strategies to improve surrogate misunderstanding of physician prognostic estimates.