Building Relationship, Improving Dialogue, and Growing Empathy (BRIDGE): An intervention to support decision-making for critically ill children

Over half a million infants and children are admitted to an intensive care unit (ICU) each year. Existing data suggest that the number, complexity, and cost of neonatal and pediatric ICU admissions is increasing and that a growing proportion of children admitted to the ICU use life-sustaining technology. Our group and others have demonstrated that shared decision-making in this setting is incomplete and that parents may experience decisional conflict, poor quality communication, and unmet information needs. To address these gaps in care, we worked with community advisors to develop and refine the Building Relationship, Improving Dialogue, and Growing Empathy (BRIDGE) intervention. The BRIDGE intervention provides parents with a brief tool that includes an introduction to health care decision-making, a values clarification exercise, and a question prompt list. Open-ended prompts additionally invite parents to describe how they define concepts like quality of life and suffering. Parents can choose to share their responses with the health care team. We propose to test the impact of the BRIDGE intervention on decision-making and communication in a 3-site randomized controlled trial, with embedded analyses to identify facilitators and barriers to BRIDGE implementation. In Aim 1, we will test the BRIDGE intervention’s impact on the quality of decision-making and communication. We will enroll parents (n=up to 300) of critically ill children (n=150) < 2 years of age for whom a decision about life-sustaining treatment or major intervention is anticipated. Parents will complete baseline surveys and will be randomized 1:1 at the level of the child to receive the BRIDGE intervention or usual care. Parents in the intervention arm will complete the BRIDGE intervention within 5 days of enrollment. All participants will complete in-hospital follow-up surveys measuring preparedness for decision-making, decisional conflict, shared decision-making, and communication quality. In Aim 2, we will evaluate the intervention’s impact on parent decisional regret, parent self-efficacy, and the evolution of parent values at 6 months. Parents will complete measures of self- efficacy and decisional regret at 6 months following hospital discharge. We will conduct semi-structured interviews with a purposively sampled group of parents (n=60) to characterize how their decision-relevant values evolved over the course of their child’s care trajectory. In Aim 3, we will characterize clinician-perceived barriers and facilitators to the implementation of the BRIDGE intervention. Using a mixed methods approach, we will survey and interview clinicians (n=45) about factors that helped or hindered BRIDGE efficacy and that may contribute to future implementation. We will integrate qualitative findings with parent acceptability metrics and characterize differences across ICU units and clinician roles. Our work will be completed in partnership with a Community Advisory Board, who will help guide study conduct, data analysis, and dissemination of results. The data acquired from this award will directly inform future effectiveness testing of the BRIDGE intervention and ongoing work to support children and families impacted by critical illness. Project Number: 1R01HD118955-01 | Fiscal Year: 2025 | NIH Institute/Center: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) | Principal Investigator: Monica Lemmon | Institution: DUKE UNIVERSITY, DURHAM, NC | Award Amount: $749,598 | Activity Code: R01 | Study Section: Interdisciplinary Clinical Care in Specialty Care Settings Study Section[ICSC] View on NIH RePORTER: https://reporter.nih.gov/project-details/1R01HD11895501