The majority of surrogates of patients that are critically ill want physicians to disclose their prognostic estimates even if they cannot be certain they are correct. This stems from surrogates' belief that prognostic uncertainty is simultaneously unavoidable and acceptable.

Objective Physicians and surrogate decision-makers for seriously ill patients often have different views of patients’ prognoses. We sought to understand what sources of knowledge surrogates rely on when estimating a patient’s prognosis. Design Prospective, mixed-methods study using face-to-face, semistructured interviews with surrogate decision-makers. Setting Four intensive care units at the University of California, San Francisco Medical Center in 2006 to 2007. Participants Participants were 179 surrogate decision-makers for 142 incapacitated, critically ill patients at high risk for death. Main Results Less than 2% (3 of 179) of surrogates reported that their beliefs about the patients’ prognoses hinged exclusively on prognostic information provided to them by physicians. The majority cited other factors in addition to physicians’ predictions that also contributed to their beliefs about the patients’ prognoses, including perceptions of the patient’s individual strength of character and will to live; the patient’s unique history of illness and survival; the surrogate’s own observations of the patient’s physical appearance; the surrogate’s belief that their presence at the bedside may improve the prognosis; and the surrogate’s optimism, intuition, and faith. For some surrogates, these other sources of knowledge superseded the importance of the physician’s prognostication. However, most surrogates endeavored to balance their own knowledge of the patient with physicians’ biomedical knowledge. Conclusions Surrogates use diverse types of knowledge when estimating their loved ones’ prognoses, including individualized attributes of the patient, such as their strength of character and life history, of which physicians may be unaware. Attention to these considerations may help clinicians identify and overcome disagreements about prognosis.

Background Although many physicians worry that openly discussing a poor prognosis will cause patients and families to lose hope, surrogate “decision makers’ perspectives on this topic are largely unknown. Objective To determine surrogate decision makers’ attitudes toward balancing hope and telling the truth when discussing prognosis. Design Prospective, mixed-methods cohort study. Setting 4 intensive care units at the University of California, San Francisco, Medical Center, San Francisco, California. Participants 179 surrogate decision makers for incapacitated patients at high risk for death. Measurements One-on-one, semistructured interviews with surrogates were conducted on the patients’ 5th day of receiving mechanical ventilation. Constant comparative methods were used to inductively develop a framework to describe participants’ responses. Validation methods included multidisciplinary analysis and member checking. Results Overall, 93% (166 of 179) of surrogates felt that avoiding discussions about prognosis is an unacceptable way to maintain hope. The main explanatory theme was that timely discussion of prognosis is essential to allow family members to prepare emotionally and logistically for the possibility of a patient’s death. Other themes that emerged included surrogates’ belief that an accurate understanding of a patient’s prognosis allows them to better support the patient and each other, a moral aversion to the idea of false hope, the perception that physicians have an obligation to discuss prognosis, and the notion that some surrogates look to physicians primarily for truth and seek hope elsewhere. A few surrogates (6 of 179) felt that physicians should withhold prognostic information because of a belief that discussing death could be emotionally damaging to the family or could negatively affect the patient’s health. Limitation The authors did not longitudinally assess whether early disclosure about prognosis predicts fewer adverse bereavement outcomes. Conclusion Most surrogates of critically ill patients do not view withholding prognostic information as an acceptable way to maintain hope, largely because timely discussions about prognosis help families begin to prepare emotionally, existentially, and practically for the possibility that a patient will die.

Background: Physicians will be called upon to care for patients who bear the burden of disease from the impact of climate change and ecologically irresponsible practices which harm ecosystems and contribute to climate change. However, physicians must recognize the connection between the climate, ecosystems, sustainability, and health and their responsibility and capacity in changing the status quo. Sustainable healthcare education (SHE), defined as education about the impact of climate change and ecosystem alterations on health and the impact of the healthcare industry on the aforementioned, is vital to prevention of adverse health outcomes due to the changing climate and environment. Objective: To systematically determine which and when a set of SHE objectives should be included in the medical education continuum. Design: Fifty-two SHE experts participated in a two-part modified-Delphi study. A survey was developed based on 21 SHE objectives. Respondents rated the importance of each objective and when each objective should be taught. Descriptive statistics and an item-level content validity index (CVI) were used to analyze data. Results: Fifteen of the objectives achieved a content validity index of 78% or greater. The remaining objectives had content validity indices between 58% and 77%. The preclinical years of medical school were rated as the optimal time for introducing 13 and the clinical years for introducing six of the objectives. Respondents noted the definition of environmental sustainability should be learned prior to medical school and identifying ways to improve the environmental sustainability of health systems in post-graduate training. Conclusions: This study proposes SHE objectives for the continuum of medical education. These objectives ensure the identity of the physician includes the requisite awareness and competence to care for patients who experience the impact of climate and environment on health and advocate for sustainability of the health systems in which they work. Abbreviations: CVI: Content validity index; SHE: Sustainable healthcare education