Background: Clear communication about prognosis is an essential aspect of decision-making for critically ill patients at high risk for death or functional impairment. Most experts recommend using numeric and qualitative probability terms to express prognosis, yet little is known about how physicians actually communicate prognostic information to family members of intensive care unit (ICU) patients.

Objectives: We sought to determine 1) the language used by physicians to communicate prognosis to family members of critically ill patients 2) whether physicians asked for permission to discuss prognosis prior to doing so and 3) whether physicians checked for understanding after delivering prognostic information.

Design: Multi-center, cross-sectional study

Methods: We audiotaped and transcribed 51 physician-family conferences in which there were deliberations about major end-of-life treatment decisions in ICUs of 4 hospitals in 2000-2002. Using Grounded Theory methods, we developed a coding system to identify each prognostic statement and to categorize the language that the physician used to communicate prognosis. We also determined whether physicians asked for permission to discuss prognosis and whether they checked to see if the family members understood the prognostic information they presented.

Main Results: The in-hospital mortality rate in the study cohort was 81% (41/51). Prognosis for survival was discussed in 67% of conferences (32/51) and prognosis for functional outcomes was discussed in 86% (44/51). When discussing a patient's chances for survival, physicians used absolute prognostic statements (eg:”no chance of surviving”) in 13% of conferences (4/32), numeric prognostic statements in 28% (9/32), qualitative probability statements in 78% (25/52), and non-probabilistic statements in 28% (9/32). In only 2% of conferences (1/50) did physicians ask for permission to discuss prognosis before doing so. In 74% of conferences (37/50), physicians explicitly addressed the uncertainty of outcomes for individual patients. In 12% of conferences (6/50), physicians checked to verify that families understood the prognostic information presented to them.

Conclusions: Most physicians in this study did not use numeric terms to convey prognostic information to family members of critically ill patients and a substantial proportion of prognostic statements were non-probabilistic. Physicians generally did not ask for permission to discuss prognosis nor check whether family members understood the prognostic information provided. These results provide potential targets for interventions to improve prognosis communication and decision-making in intensive care units.