title: Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients.
abstract: OBJECTIVE
  Misperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical information.
  
  
  OBJECTIVE
  To determine the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs).
  
  
  METHODS
  Mixed-methods study comprising quantitative surveys and qualitative interviews conducted in 4 ICUs at a major US medical center involving surrogate decision makers and physicians caring for patients at high risk of death from January 4, 2005, to July 10, 2009.
  
  
  METHODS
  Discordance about prognosis, defined as a difference between a physician's and a surrogate's prognostic estimates of at least 20%; misunderstandings by surrogates (defined as any difference between a physician's prognostic estimate and a surrogate's best guess of that estimate); differences in belief (any difference between a surrogate's actual estimate and their best guess of the physician's estimate).
  
  
  RESULTS
  Two hundred twenty-nine surrogate decision makers (median age, 47 [interquartile range {IQR}, 35-56] years; 68% women) and 99 physicians were involved in the care of 174 critically ill patients (median age, 60 [IQR, 47-74] years; 44% women). Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related to both misunderstandings by surrogates and differences in belief about the patient's prognosis; 38 (17%) were related to misunderstandings by surrogates only; 7 (3%) were related to differences in belief only; and data were missing for 12. Seventy-five patients (43%) died. Surrogates' prognostic estimates were much more accurate than chance alone, but physicians' prognostic estimates were statistically significantly more accurate than surrogates' (C statistic, 0.83 vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163; P = .008). Among 71 surrogates interviewed who had beliefs about the prognosis that were more optimistic than that of the physician, the most common reasons for optimism were a need to maintain hope to benefit the patient (n = 34), a belief that the patient had unique strengths unknown to the physician (n = 24), and religious belief (n = 19).
  
  
  CONCLUSIONS
  Among critically ill patients, discordant expectations about prognosis were common between patients' physicians and surrogate decision makers and were related to misunderstandings by surrogates about physicians' assessments of patients' prognoses and differences in beliefs about patients' prognoses.
authors.affiliation: Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Douglas B
authors.initials: DB
authors.lastname: White
authors.affiliation: Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Natalie
authors.initials: N
authors.lastname: Ernecoff
authors.affiliation: Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Praewpannarai
authors.initials: P
authors.lastname: Buddadhumaruk
authors.affiliation: Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Seoyeon
authors.initials: S
authors.lastname: Hong
authors.affiliation: Statistics Collaborative, Washington, DC.
authors.forename: Lisa
authors.initials: L
authors.lastname: Weissfeld
authors.affiliation: Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Washington, Seattle.
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
authors.affiliation: Pulmonary, Critical Care, Allergy, and Sleep Medicine Program, Department of Medicine, University of California, San Francisco.
authors.forename: John M
authors.initials: JM
authors.lastname: Luce
authors.affiliation: Program in Medical Ethics, Department of Medicine, University of California, San Francisco.
authors.forename: Bernard
authors.initials: B
authors.lastname: Lo
mesh_terms: D000328:Adult; D000368:Aged; D001290:Attitude; D032882:Comprehension; D016638:Critical Illness; D003469:Culture; D003657:Decision Making; D034462:Dissent and Disputes; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010820:Physicians / Q000706:statistics & numerical data*; D011336:Probability; D011379:Prognosis; D019727:Proxy / Q000706:statistics & numerical data*; D036301:Qualitative Research; D013727:Terminal Care