Dr. Susanne Muehlschlegel is a Critical Care Neurologist at the University of Massachusetts Medical School (UMMS) whose goal is to become an independent investigator with expertise in patient outcome prediction, shared decision making, and decision-science to improve clinical decision making for patients with catastrophic brain injuries and their families. Moderate to severe traumatic brain injury (msTBI) remains the leading cause of death after trauma which mostly follows withdrawal of care. Dr. Muehlschlegel will tackle the life-or-death decision about continuation or withdrawal of care (goals-of-care) in msTBI patients and develop a decision aid for health care proxies of these critically ill patients. Dr. Muehlschlegel's career development plan brings together an outstanding team of investigators from three leading institutions, including the UMMS, University of New England, and University of Pittsburgh. Dr. Muehlschlegel has already obtained preliminary results in msTBI patients confirming that intensive care unit (ICU) complications are associated with worse short-term functional patient outcomes and mortality, and also lead to worse subjective prognostication by clinicians. Based on her daily interactions with families of msTBI patients in her unique clinical position as a neuroICU physician, Dr. Muehlschlegel is acutely aware of the need to improve prognostication and its communication between physicians and families while also including patient's values and preferences. Under the mentorship of Drs. Goldberg, Col, Shutter and Mazor, Dr. Muehlschlegel proposes to: (1a) identify key psychosocial factors of goals-of-care decisions in health care proxies of msTBI patients and physicians in focus groups and structured interviews; (1b) develop a new outcome prediction score for msTBI patients including ICU complications and previously validated admission predictors in a prospectively collected hospital-based cohort of patients with msTBI and to validate her findings internally; (2) create a decision aid prototype for goals-of- care decisions in msTBI patients by incorporating results from Aims 1a and 1b, and the well known and validated msTBI outcome prediction IMPACT score based on hospital admission variables; and (3) to pilot test the decision aid in a feasibility trial in the neuroICU. The overal goal of this proposal is to develop a goals- of-care decision aid that may improve health outcomes for msTBI patients by ensuring proxies receive evidence-based prognostication, understand projected outcomes and risks, while also addressing patient's preferences and values. This well-defined mentored patient-oriented research proposal will bring together cutting-edge qualitative and quantitative methods for decision aid and outcome prediction rule derivation, and a team with expertise in outcomes research, shared decision making, and neurocritical care of msTBI patients. This proposal, in concert with a structured didactic curriculum of advanced statistical, qualitative, and decision- science coursework, will provide Dr. Muehlschlegel with the skills and mentorship that are essential for her to develop an independent career in neuroICU research at the cutting edge of shared decision making science.