Tuesday, May 17, 2016

Prognosis discordance between physicians and surrogate decision makers of critically ill patients

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.


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.


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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