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Original Investigation | Caring for the Critically Ill Patient

Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients

Douglas B. White, MD, MAS1; Natalie Ernecoff, MPH1; Praewpannarai Buddadhumaruk, RN, MS1; Seoyeon Hong, PhD1; Lisa Weissfeld, PhD2; J. Randall Curtis, MD, MPH3; John M. Luce, MD4; Bernard Lo, MD5
[+] Author Affiliations
1Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
2Statistics Collaborative, Washington, DC
3Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Washington, Seattle
4Pulmonary, Critical Care, Allergy, and Sleep Medicine Program, Department of Medicine, University of California, San Francisco
5Program in Medical Ethics, Department of Medicine, University of California, San Francisco
JAMA. 2016;315(19):2086-2094. doi:10.1001/jama.2016.5351.
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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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Figure 1.
Probability Scale Used to Record Study Participants’ Prognostic Estimates of Patients’ Survival to Hospital Discharge and Example Responses

Physicians (A) and surrogates (C) independently recorded their estimates of the patient’s chances of survival to hospital discharge in response to the question “What do you think are the chances that the patient/your loved one will survive this hospitalization if the current plan of care stays the same?” Surrogates also recorded their perceptions of the physician’s prognostic estimate (B). Not all surrogates and physicians reported that a conversation about prognosis had occurred and therefore, some surrogates had no explicit prognostic information from physicians on which to base their estimates. Physician-surrogate discordance was defined as physician-surrogate differences of at least 20% (difference between A and C). Differences of any magnitude between the surrogate’s prognostic estimate (C) and the surrogate’s perceptions of the physician’s prognostic estimate (B) were classified as differences in belief. Differences of any magnitude between the physician’s prognostic estimate (A) and the surrogate’s perceptions of the physician’s prognostic estimate (B) were classified as surrogate misunderstandings.

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Figure 2.
Receiver Operating Characteristic Curves for Accuracy of Prognostic Estimates of Patient Survival to Hospital Discharge

On the patient’s fifth day of mechanical ventilation, surrogates and physicians independently estimated the probability that the patient would survive the hospitalization (on a 0%-100% scale). Receiver operating characteristic curves were generated using mixed-effects regression models with patients nested within surrogates within physicians, patient mortality as a dependent variable, surrogate and physician survival estimates as independent variables, and physician as a random intercept (see eAppendix in the Supplement for additional details). The dotted diagonal line represents no predictive power. The prognostic accuracy of physicians was superior to that of surrogates (P = .008).

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