(1784) Decision-Making and Family Impact in Potentially Futile Interhospital Transfers: What Caregivers Say

Introduction: At least 1.6 million patients are transferred each year in the U.S. Interhospital transfer (IHT) is associated with increases in length of stay, cost, and inpatient mortality, as well as family and clinician distress. Little is known about communication around high-risk transfer. We sought to explore family perceptions of decision-making and care in potentially futile transfer, i.e. transfer within 72 hours of death.

Methods: We conducted semi-structured interviews with surrogates of patients who died after IHT to a Southeastern academic center between 2020 and 2022. Three coders engaged in consensus-building discussions to develop a codebook and to achieve perfect agreement on coding. Codes were then analyzed using reflexive thematic analysis.

Results: A total of 32 surrogates were interviewed, predominantly spouses (15/32; 46.9%). The median patient age was 69.5, and 59.3% (19) of patients were white. 19 (59.3%) were transferred >50 miles.
Key themes included (1) limited surrogate engagement in transfer decision-making, (2) limited prognostic awareness pre-transfer, and (3) logistical challenges presented by transfer. Many caregivers reported minimal involvement in transfer decision-making, although a few initiated transfers in the context either of an existing relationship with the receiving hospital or due to extreme dissatisfaction with perceived quality of care at the transferring hospital. Surrogates described a lack of prognostic awareness of the severity of the patient’s pre-transfer medical problems. Respondents also reported logistical difficulties imposed by distance and Covid-related visiting restrictions, including communication gaps pre- and post-transfer. While some caregivers felt that transfer enabled them to explore all possible treatment options, others felt that it was too late or regretted the transfer due to the burdens it imposed on the patient/family.

Conclusions: Interhospital transfer is a care transition with significant impact upon patient and families, yet rarely is treated as a preference-sensitive intervention. Opportunities exist for intensivists at transferring and receiving hospitals to discuss goals of care and set expectations regarding transfer and its potential outcomes.