Clinician predictions of intensive care unit mortality.
OBJECTIVE
Predicting outcomes for critically ill patients is an important aspect of discussions with families in the intensive care unit. Our objective was to evaluate clinical intensive care unit survival predictions and their consequences for mechanically ventilated patients.


METHODS
Prospective cohort study.


METHODS
Fifteen tertiary care centers.


METHODS
Consecutive mechanically ventilated patients > or = 18 yrs of age with expected intensive care unit stay > or = 72 hrs.


METHODS
We recorded baseline characteristics at intensive care unit admission. Daily we measured multiple organ dysfunction score (MODS), use of advanced life support, patient preferences for life support, and intensivist and bedside intensive care unit nurse estimated probability of intensive care unit survival.


RESULTS
The 851 patients were aged 61.2 (+/- 17.6, mean + SD) yrs with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 21.7 (+/- 8.6). Three hundred and four patients (35.7%) died in the intensive care unit, and 341 (40.1%) were assessed by a physician at least once to have a < 10% intensive care unit survival probability. Independent predictors of intensive care unit mortality were baseline APACHE II score (hazard ratio, 1.16; 95% confidence interval, 1.08-1.24, for a 5-point increase) and daily factors such as MODS (hazard ratio, 2.50; 95% confidence interval, 2.06-3.04, for a 5-point increase), use of inotropes or vasopressors (hazard ratio, 2.14; 95% confidence interval, 1.66-2.77), dialysis (hazard ratio, 0.51; 95% confidence interval, 0.35-0.75), patient preference to limit life support (hazard ratio, 10.22; 95% confidence interval, 7.38-14.16), and physician but not nurse prediction of < 10% survival. The impact of physician estimates of < 10% intensive care unit survival was greater for patients without vs. those with preferences to limit life support (p < .001) and for patients with less vs. more severe organ dysfunction (p < .001). Mechanical ventilation, inotropes or vasopressors, and dialysis were withdrawn more often when physicians predicted < 10% probability of intensive care unit survival (all ps < .001).


CONCLUSIONS
Physician estimates of intensive care unit survival < 10% are associated with subsequent life support limitation and more powerfully predict intensive care unit mortality than illness severity, evolving or resolving organ dysfunction, and use of inotropes or vasopressors.
Rocker
Graeme
G
Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
Cook
Deborah
D
Sjokvist
Peter
P
Weaver
Bruce
B
Finfer
Simon
S
McDonald
Ellen
E
Marshall
John
J
Kirby
Anne
A
Levy
Mitchell
M
Dodek
Peter
P
Heyland
Daren
D
Guyatt
Gordon
G
D018806:APACHE; D016009:Chi-Square Distribution; D002983:Clinical Competence / Q000592:standards*; D016638:Critical Illness / Q000401:mortality* / Q000628:therapy; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D016013:Likelihood Functions; D008297:Male; D008505:Medical Staff, Hospital / Q000592:standards*; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000145:classification / Q000401:mortality; D009730:Nursing Assessment / Q000592:standards; D009741:Nursing Staff, Hospital / Q000592:standards*; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012121:Respiration, Artificial; D012307:Risk Factors; D012720:Severity of Illness Index; D016019:Survival Analysis