Douglas B. White, Natalie Ernecoff, Praewpannarai
Buddadhumaruk, Seoyeon Hong, Lisa Weissfeld, J. Randall Curtis, John M. Luce, Bernard
Lo. Prevalence of and Factors Related to
Discordance About Prognosis Between Physicians and Surrogate Decision Makers of
Critically Ill Patients. JAMA. 2016;315(19):2086-2094.
Abstract
Importance
Misperceptions about prognosis by individuals making decisions for
incapacitated critically ill patients (surrogates) are common and often
attributed to poor comprehension of medical information.
Objective To
determine the prevalence of and factors related to physician-surrogate
discordance about prognosis in intensive care units (ICUs).
Design, Setting, and Participants Mixed-methods study comprising quantitative
surveys and qualitative interviews conducted in 4 ICUs at a major US medical
center involving surrogate decision makers and physicians caring for patients
at high risk of death from January 4, 2005, to July 10, 2009.
Main Outcomes and Measures
Discordance about prognosis, defined as a difference between a
physician’s and a surrogate’s prognostic estimates of at least 20%;
misunderstandings by surrogates (defined as any difference between a
physician’s prognostic estimate and a surrogate’s best guess of that estimate);
differences in belief (any difference between a surrogate’s actual estimate and
their best guess of the physician’s estimate).
Results Two hundred
twenty-nine surrogate decision makers (median age, 47 [interquartile range
{IQR}, 35-56] years; 68% women) and 99 physicians were involved in the care of
174 critically ill patients (median age, 60 [IQR, 47-74] years; 44% women).
Physician-surrogate discordance about prognosis occurred in 122 of 229
instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related
to both misunderstandings by surrogates and differences in belief about the
patient’s prognosis; 38 (17%) were related to misunderstandings by surrogates
only; 7 (3%) were related to differences in belief only; and data were missing
for 12. Seventy-five patients (43%) died. Surrogates’ prognostic estimates were
much more accurate than chance alone, but physicians’ prognostic estimates were
statistically significantly more accurate than surrogates’ (C statistic, 0.83
vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163; P = .008). Among 71
surrogates interviewed who had beliefs about the prognosis that were more
optimistic than that of the physician, the most common reasons for optimism
were a need to maintain hope to benefit the patient (n = 34), a belief that the
patient had unique strengths unknown to the physician (n = 24), and religious
belief (n = 19).
Conclusions and Relevance
Among critically ill patients, discordant expectations about prognosis
were common between patients’ physicians and surrogate decision makers and were
related to misunderstandings by surrogates about physicians’ assessments of
patients’ prognoses and differences in beliefs about patients’ prognoses.
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However, "it isn't just a misunderstanding of the
patient's prognosis that is causing the family and friends of that patient to
have significantly different estimates for their loved one's survival than that
of their doctor," said study lead author Dr. Douglas White.
The surrogates' personal beliefs influence their outlook,
said White, a professor of critical care medicine at the University of Pittsburgh
Medical Center.
Some surrogate decision makers believe that if they
"hope the patient does well it will be good for the patient, or that the
patient has strengths that the doctor does not know about," he explained.
"And religious beliefs that a higher power may save the patient also come
into play.
"Doctors should be aware of everything that may go into
a surrogate decision maker's thinking when conveying a prognosis and laying out
potential care options," White said.
After comparing surrogate answers to those of 99 physicians
on duty, the study authors found that 53 percent of the time there was at least
a 20 percent gap in the way surrogates and doctors viewed a patient's
prospects.
Surrogates gravitated toward more optimistic prognoses. But
the doctors were found to have expressed more accurate views, given the ultimate
outcomes (and deaths of more than 40 percent of the patients), the study found.
Among surrogates who expressed overly optimistic views, only
17 percent said they had misunderstood medical information. Roughly one-third
(71 surrogates) maintained a more positive view than the physician, despite
having understood the information provided.
Why? Almost half of the 71 said they felt that maintaining
hope was helpful to the patient. About one-third referenced their more intimate
knowledge of the patient's capabilities, while a little more than one-quarter
cited their religious beliefs.
Dr. Elie Azoulay, lead author of an accompanying editorial
in the journal, said very often family members are simply looking for the
intimacy and time they need to adjust to a new reality, rather than more
medical detail.
"[It's] not that they did not understand or that they
cannot grasp medical information," said Azoulay, deputy director of the
intensive care medical unit at Saint-Louis Hospital in Paris, France.
"They just don't want to hear what we said and how we said it."
So Azoulay suggested that physicians view the family-doctor
divide "as an opportunity to change our way to communicate, better address
family needs and provide active listening."
Doctors should talk less and listen more, while providing
loved ones "with opportunities to voice concerns, vent emotions, or
sometimes just to be there with the team without hearing or saying a
word," Azoulay said.
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