Differing Expectations for Critically Ill

More than half of the family and friends making decisions for critically ill patients have significantly different estimates for the patient’s survival than the doctor—and that’s not only because of a misunderstanding, according to University of Pittsburgh School of Medicine researchers.

The findings were reported in a recent issue of the Journal of the American Medical Association.

The majority of those differences were due to the decision maker holding fundamentally different and overly optimistic beliefs about the patient’s prognosis. The research team anticipates that this finding will help train physicians to better communicate with the patient’s family and friends so they can make the best decisions for their loved one.  

“It isn’t a bad thing for a patient’s family and friends to have hope that they will recover,” said lead author Douglas B. White, a professor in Pitt’s Department of Critical Care Medicine and director of the department’s Program on Ethics and Decision Making. “However, it is problematic when those overly optimistic expectations result in more invasive treatments in dying patients—and delayed integration of palliative care that can alleviate suffering.”

Between 2005 and 2009, White and his colleagues surveyed 229 people who had agreed to be the “surrogate decision maker” for hospitalized patients in four intensive care units at the University of California, San Francisco Medical Center, where White previously was a faculty member. These surrogates were typically family members or friends of the patient. They also surveyed the physicians caring for those patients. 

The researchers asked both the surrogates and the doctors to estimate the chances that the patient would survive hospitalization on a scale of 0 (no chance of survival) to 100 (definite survival). They did not know each other’s answers.

In 53 percent of cases, the answers differed by more than 20 percent. The surrogates were usually more optimistic than the doctors, but the doctors’ estimates of the patient prognosis were ultimately far more accurate.

The researchers then asked the surrogates to guess what they thought the patient’s doctor answered. Generally, the surrogates would guess somewhere in between their estimate and the doctor’s real estimate, indicating that the surrogates understood they were being more optimistic than what the doctor had been communicating to them.

The surrogates explained this in many ways, the most common being that they believed if they maintained hope, then the patient would do better than expected— or that they knew the patient better than the doctor and believed the patient had strengths the doctor didn’t know about. They also often had an optimism grounded in religious beliefs.

“As doctors, we want to provide the best possible care for our patients. In critically ill patients, that means we must do a better job communicating with the people who are making decisions for our patients,” said White, who also holds the UPMC Endowed Chair for Ethics in Critical Care Medicine. “Given the results of this study, we’re working to develop and test interventions, both to improve the comprehensibility of the prognosis doctors give to surrogates and to better attend to the emotional and psychological factors that may influence the surrogate’s expectations for their loved one’s outcome.”