Prognostication during physician-family discussions about limiting life support in intensive care units.
OBJECTIVE
Prognostic information is important to the family members of incapacitated, critically ill patients, yet little is known about what prognostic information physicians provide. Our objectives were to determine the types of prognostic information provided to families of critically ill patients when making major end-of-life treatment decisions and to identify factors associated with more physician prognostication.


METHODS
Multiple-center, cross-sectional study.


METHODS
ICUs of four hospitals.


METHODS
Thirty-five physicians, 51 patients, and 169 family members.


METHODS
We audiotaped 51 physician-family conferences in which there were deliberations about major end-of-life treatment decisions at four hospitals in 2000-2002. Conferences were coded to identify the types of prognostic information provided by physicians. We used a mixed-effects regression model to identify factors associated with more prognostication by physicians.


RESULTS
The mean number of prognostic statements per conference was 9.4+/-6.4 (range 0-29). Eighty-six percent of conferences contained discussion of the patient's anticipated functional status or quality of life, compared with 63% in which the chances for survival were discussed (p=.01). There were significantly more statements about prognosis for functional outcomes per conference compared with statements about prognosis for survival (median 4 [interquartile range 2-8] vs. 1 [interquartile range 0-3]; p<.001). Increasing educational level of the family was independently associated with more prognostic statements by physicians (p<.001) as was the degree of physician-family conflict about withdrawing life support (p<.001) and the physician's race being white (p=.009).


CONCLUSIONS
Prognostication occurred frequently during physician-family deliberations about whether to forego life support, but physicians did not discuss the patient's prognosis for survival in more than one third of conferences. Less educated families received less information about prognosis. Future studies should address whether these observations partially explain the high prevalence of family misunderstandings about prognosis in intensive care units.
White
Douglas B
DB
Division of Pulmonary and Critical Care Medicine, Program in Medical Ethics, Department of Medicine, University of California, San Francisco, USA.
Engelberg
Ruth A
RA
Wenrich
Marjorie D
MD
Lo
Bernard
B
Curtis
J Randall
JR
D000328:Adult; D003422:Critical Care / Q000941:ethics*; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care / Q000941:ethics*; D008297:Male; D008875:Middle Aged; D011368:Professional-Family Relations; D011379:Prognosis; D014342:Truth Disclosure