Among critically ill patients, expectations about prognosis often differ between physicians and surrogate decision makers, and the causes are more complicated than the surrogate simply misunderstanding the physicians' assessments of prognosis, according to a study appearing in the May 17 issue of JAMA.
In 2010, it was estimated that nearly half of U.S. adults near the end of life were unable to make decisions for themselves about whether to accept life-prolonging technologies. Family members or other individuals are asked to serve as surrogate decision makers for these often difficult decisions. Douglas B. White, M.D., M.A.S., of the University of Pittsburgh Medical Center, Pittsburgh, and colleagues examined the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs). The study included surveys and qualitative interviews conducted in 4 ICUs at a major U.S. medical center involving surrogate decision makers and physicians caring for patients at high risk of death.
Two hundred twenty-nine surrogate decision makers and 99 physicians were involved in the care of 174 critically ill patients. Physician-surrogate discordance about prognosis (defined as a difference between a physician's and a surrogate's prognostic estimates of at least 20 percent) occurred in 122 of 229 instances (53 percent). In 65 instances (28 percent), discordance was related to both misunderstandings by surrogates and differences in belief about the patient's prognosis; 17 percent were related to misunderstandings by surrogates only; 3 percent were related to differences in belief only; and data were missing for 12.
Seventy-five patients (43 percent) died. Surrogates' prognostic estimates were much more accurate than chance alone, but physicians' prognostic estimates were statistically significantly more accurate than surrogates'. 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).
"There are at least 2 clinical implications of our findings. First, given the high rates of discordance about prognosis, clinicians communicating with surrogates of patients with advanced critical illness should routinely check in with surrogates about their perceptions of prognosis prior to engaging in decision making about goals of care," the authors write.
"Second, when clinicians recognize that surrogates' expectations about prognosis diverge from their own, they should explore the possibility that causes other than misunderstanding may be contributing, such as a belief that the patient is stronger than average, a belief that expressing optimism will improve the patient's outcome, or a belief that religious rather than biomedical considerations will determine the patient's outcome. This is important because interventions to reconcile discordance about prognosis may differ for misunderstandings compared with differences in belief."