title: Physicians' decision-making roles for an acutely unstable critically and terminally ill patient.
abstract: OBJECTIVE
  There is substantial variation in use of life sustaining technologies in patients near the end of life but little is known about variation in physicians' initial ICU admission and intubation decision making processes. Our objective is to describe variation in hospital-based physicians' communication behaviors and decision-making roles for ICU admission and intubation decisions for an acutely unstable critically and terminally ill patient.
  
  
  METHODS
  We conducted a secondary analysis of transcribed simulation encounters from a multi-center observational study of physician decision making. The simulation depicted a 78-year-old man with metastatic gastric cancer and life threatening hypoxia. He has stable underlying preferences against ICU admission and intubation that he or his wife will report if asked. We coded encounters for communication behaviors (providing medical information, eliciting preferences/values, engaging the patient/surrogate in deliberation, and providing treatment recommendations) and used a previously-developed framework to classify subject physicians into four -mutually-exclusive decision-making roles: informative (providing medical information only), facilitative (information + eliciting preferences/values + guiding surrogate to apply preferences/values), collaborative (information + eliciting + guiding + making a recommendation) and directive (making an independent treatment decision).
  
  
  METHODS
  Simulation centers at 3 US academic medical centers.
  
  
  METHODS
  Twenty-four emergency physicians, 37 hospitalists, and 37 intensivists.
  
  
  RESULTS
  Subject physicians average 12.4 years (SD 9.0) since graduation from medical school. Of 98 physicians (39%), 38 physicians sent the patient to the ICU, and 9 of 98 (9%) ultimately decided to intubate. Most (93 of 98 [95%]) provided at least some medical information, but few explained the short-term prognosis with (26 of 98 [27%]) or without intubation (37 of 98 [38%]). Many (80 of 98 [82%]) elicited the patient's intubation preferences, but few (35 of 98 [36%]) explored the patient's broader values. Based on coded behaviors, we categorized 1 of 98 (1%) as informative, 48 of 98 (49%) as facilitative, 36 of 98 (37%) as collaborative, and 12 of 98 (12%) as directive; 1 of 98 (1%) could not be placed into a category. No observed physician characteristics predicted decision-making role.
  
  
  CONCLUSIONS
  The majority of the physicians played a facilitative or collaborative role, although a greater proportion assumed a directive role in this time-pressured scenario than has been documented in nontime-pressured ICU family meetings, suggesting that physicians' roles may be context dependent.
authors.affiliation: Office of the Med-Dean, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Jamie
authors.initials: J
authors.lastname: Uy
authors.forename: Douglas B
authors.initials: DB
authors.lastname: White
authors.forename: Deepika
authors.initials: D
authors.lastname: Mohan
authors.forename: Robert M
authors.initials: RM
authors.lastname: Arnold
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
mesh_terms: D000328:Adult; D000368:Aged; D003142:Communication; D016638:Critical Illness / Q000628:therapy*; D003657:Decision Making; D006801:Humans; D000860:Hypoxia / Q000628:therapy; D007362:Intensive Care Units; D007442:Intubation, Intratracheal; D008020:Life Support Care / Q000379:methods; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D057240:Patient Preference; D016544:Patient Simulation; D010817:Physician-Patient Relations; D010820:Physicians / Q000523:psychology*; D011379:Prognosis; D013274:Stomach Neoplasms / Q000473:pathology / Q000628:therapy; D013727:Terminal Care / Q000379:methods*
references.citation: J Clin Ethics. 2011 Fall;22(3):267-76
references.pmid: 22167990
references.citation: Am J Hosp Palliat Care. 2009 Dec-2010 Jan;26(6):464-9
references.pmid: 19648574
references.citation: J Palliat Med. 2010 Aug;13(8):949-56
references.pmid: 20642362
references.citation: Crit Care Med. 2010 Mar;38(3):743-50
references.pmid: 20029347
references.citation: J Gen Intern Med. 2008 Nov;23(11):1877-82
references.pmid: 18800206
references.citation: BMJ. 1999 Sep 18;319(7212):780-2
references.pmid: 10488014
references.citation: Crit Care Med. 2008 Dec;36(12):3156-63
references.pmid: 18936694
references.citation: BMJ. 2004 Mar 13;328(7440):607
references.pmid: 15016692
references.citation: Crit Care Med. 2011 Jul;39(7):1663-9
references.pmid: 21460710
references.citation: J Gen Intern Med. 2011 Apr;26(4):359-66
references.pmid: 21104036
references.citation: Ann Intern Med. 2003 Feb 18;138(4):273-87
references.pmid: 12585825