Surrogate decision makers' responses to physicians' predictions of medical futility.
BACKGROUND
Although physicians sometimes use the futility rationale to limit the use of life-sustaining treatments, little is known about how surrogate decision makers view this rationale. We sought to determine the attitudes of surrogates of patients who are critically ill toward whether physicians can predict futility and whether these attitudes predict surrogates' willingness to discontinue life support when faced with predictions of futility.


METHODS
This multicenter, mixed qualitative and quantitative study took place at three hospitals in California from 2006 to 2007. We conducted semistructured interviews with surrogate decision makers for 50 patients who were critically ill and incapacitated that addressed their beliefs about medical futility and inductively developed an organizing framework to describe these beliefs. We used a hypothetical scenario with a modified time-trade-off design to examine the relationship between a patient's prognosis and a surrogate's willingness to withdraw life support. We used a mixed-effects regression model to examine the association between surrogates' attitudes about futility and their willingness to limit life support in the face of a very poor prognosis. Validation methods included the use and integration of multiple data sources, multidisciplinary analysis, and member checking.


RESULTS
Sixty-four percent of surrogates (n = 32; 95% confidence interval [CI], 49 to 77%) expressed doubt about the accuracy of physicians' futility predictions, 32% of surrogates (n = 16; 95% CI, 20 to 47%) elected to continue life support with a < 1% survival estimate, and 18% of surrogates (n = 9; 95% CI, 9 to 31%) elected to continue treatment when the physician believed that the patient had no chance of survival. Surrogates with religious objections to the futility rationale (n = 18) were more likely to request continued life support (odds ratio, 4; 95% CI, 1.2 to 14.0; p = 0.03) than those with secular or experiential objections (n = 15; odds ratio, 0.95; 95% CI, 0.3 to 3.4; p = 0.90).


CONCLUSIONS
Doubt about physicians' ability to predict medical futility is common among surrogate decision makers. The nature of the doubt may have implications for responding to conflicts about futility in clinical practice.
Zier
Lucas S
LS
University of California, Berkeley-University of California, San Francisco Joint Medical Program, School of Public Health, University of California, Berkeley, CA.
Burack
Jeffrey H
JH
University of California, Berkeley-University of California, San Francisco Joint Medical Program, School of Public Health, University of California, Berkeley, CA; Division of Community Health and Human Development, School of Public Health, University of California, Berkeley, CA; East Bay AIDS Research Institute, Alta Bates Summit Medical Center, Oakland, CA.
Micco
Guy
G
University of California, Berkeley-University of California, San Francisco Joint Medical Program, School of Public Health, University of California, Berkeley, CA; Division of Community Health and Human Development, School of Public Health, University of California, Berkeley, CA.
Chipman
Anne K
AK
University of California, Berkeley-University of California, San Francisco Joint Medical Program, School of Public Health, University of California, Berkeley, CA.
Frank
James A
JA
The San Francisco Veterans Affairs Medical Center, San Francisco, CA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA.
White
Douglas B
DB
School of Medicine, and the Program in Medical Ethics, Department of Medicine, University of California, San Francisco, CA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA. Electronic address: dwhite@medicine.ucsf.edu.