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Tuesday, October 23, 2007 - 5:15 PM
H-6

DOUBT ABOUT PHYSICIANS' ABILITY TO PROGNOSTICATE IN CRITICAL ILLNESS: INTERVIEWS WITH SURROGATE DECISION MAKERS

Douglas B. White, MD, MAS, University of California, San Francisco, San Francisco, CA, Lucas Zier, 1UC Berkeley-UC San Francisco Joint Medical Program, School of Public Health, University of California, Berkeley, Berkeley, CA, Jeffrey A. Burack, MD, M.Phil, UC Berkeley-UC San Francisco Joint Medical Program, School of Public Health, University of California, Berkeley, Berkeley, CA, James Frank, MD, University of California, San Francisco; San Francisco VA Medical Center, San Francisco, CA, and John M. Luce, MD, University of California, San Francisco; San Francisco General Hospital, San Francisco, CA.

PURPOSE: Although discussing prognosis with surrogate decision makers is a duty of physicians caring for patients at high risk of death, little is known about surrogates' attitudes toward physicians' ability to prognosticate. We sought to determine 1) surrogates' attitudes about whether physicians can accurately prognosticate for patients in intensive care units and 2) how individuals use prognostic information in their role as surrogate decision makers.

METHODS: We conducted a multicenter, cross-sectional study in which we performed semi-structured interviews with 50 surrogate decision-makers of critically ill patients. We analyzed the interview transcripts using grounded theory methods to inductively develop a framework to describe surrogates' attitudes about prognostication. Validation methods included triangulation by multidisciplinary analysis and member checking.

RESULTS: Overall, 88% (44/50) of surrogates expressed doubt in physicians' ability to prognosticate for critically ill patients. Participants identified several distinct reasons why they doubted physicians' prognostic estimates, including the belief that God could alter the course of the illness, the inherent inaccuracies of predicting future events, and prior experiences in which physicians' prognostications were inaccurate. Participants also identified several factors that led to confidence in prognostic information from physicians, including the perception that the treating physician was highly experienced, receiving similar prognostic estimates from multiple physicians, and prior experiences in which prognostic estimates were accurate. Surrogates unanimously endorsed the importance of receiving physicians' prognostic estimates. Rather than using prognostic information as the sole factor in decision-making, most surrogate decision-makers use it as one piece of information to inform their decision. Most surrogates felt that being told early of a patient's poor prognosis would help them begin to prepare emotionally and logistically for the possibility that the patient may not survive.

CONCLUSIONS: Although surrogate decision makers value prognostic disclosure from physicians, the vast majority harbor doubt about its accuracy and many would disregard it when deciding whether to limit life support for an incapacitated critically ill patient. Most surrogates have a fundamentally different conception of what determines whether a patient will live or die than the traditional biomedical model.


See more of Concurrent Abstracts H: Preferences and Behaviors of Patients and Providers
See more of The 29th Annual Meeting of the Society for Medical Decision Making (October 20-24, 2007)