Effect of Documenting Prognosis on the Information Provided to ICU Proxies: A Randomized Trial*

Abstract

Objectives: The Critical Care Choosing Wisely Task Force recommends that intensivists offer patients at high risk for death or severe functional impairment the option of pursuing care focused on comfort. We tested the a priori hypothesis that intensivists who are prompted to document patient prognosis are more likely to disclose prognosis and offer comfort-focused care. Design: Randomized controlled trial (clinicaltrials.gov:). Setting: High-fidelity Simulation Center in Baltimore, MD. Participants: One hundred sixteen intensivists from 17 states. Intervention: All intensivists reviewed a paper-based medical record for a hypothetical patient on ICU day 3 and answered four survey questions about the patient’s medical management. Intensivists randomized to the intervention group answered three additional questions about patient prognosis. Thereafter, each intensivist participated in a standardized, video-recorded, simulated family meeting with an actor performing a standardized portrayal of the patient’s daughter. Measurements and Main Results: Two blinded intensivists reviewed deidentified written transcripts of all simulated family meetings. The primary outcome was the blinded reviewers’ assessment that the intensivist had presented the option of care focused entirely on comfort. Secondary outcomes included disclosing risk of death. All outcomes were planned prior to data collection. Among the 63 intensivists randomized to the intervention, 50 (79%) expected the patient to die during the hospitalization and 58 (92%) expected the patient to have new functional impairments preventing independent living. Intensivists in the intervention versus control group were no more likely to offer the option of care focused on comfort (13% vs 13%; 95% CI, −13% to 12%; p = 1.0) but were more likely to inform the daughter that her father was sick enough to die (68% vs 43%; 95% CI, 5–44%; p = 0.01). Conclusions: Documenting prognosis may help intensivists disclose prognosis to ICU proxies, but in isolation, it is unlikely to change the treatment options offered during initial family meetings.

Physicians’ predictions of long-term survival and functional outcomes do not influence the decision to admit patients with advanced disease to intensive care: A prospective study

“…In simulation studies, ICU physicians asked to estimate a patient’s survival and functional prognosis were more likely to discuss treatment withdrawal or to inform a family member of the patient’s high risk of dying. 32,33…”

“…In simulation studies, ICU physicians asked to estimate a patient's survival and functional prognosis were more likely to discuss treatment withdrawal or to inform a family member of the patient's high risk of dying. 32,33 Advance care planning and goals of care discussions are part of comprehensive palliative care and are considered useful in decreasing high intensity care at the end of life, including admission to the ICU. 34−37 Barriers to optimal discussions include physicians' discomfort and lack of skills in addressing end-of-life issues.…”

Outcome Prediction after Moderate and Severe Traumatic Brain Injury: External Validation of Two Established Prognostic Models in 1742 European Patients

“…Treatment options for TBI patients are scarce, and documenting prognosis in the intensive care setting does not seem to substantially affect treatment decisions. [25][26][27] On the other hand, there is an increasing recognition that estimates of prognosis by clinicians are often unduly pessimistic for TBI patients, 28 and regular comparison of outcome predicted by these models with clinical expectations may help individual clinicians calibrate their prognostication and practice. Based on the good discriminative ability of the IMPACT and CRASH models, potential applications in research settings are risk stratification in trials and covariate adjustment in statistical analyses to increase statistical power.…”

Aligning use of intensive care with patient values in the USA: past, present, and future

“…However, one study calls into question whether a prompt is sufficient to change the options ICU proxies are offered. In a double-blind, randomised controlled trial 103 done in a high-fidelity simulation centre, intensivists prompted to document prognosis were significantly more likely to disclose that the patient was sick enough to die during a simulated family meeting than those who were not prompted to document prognosis, but no more likely to tell the patient’s daughter that care focused on comfort was an option. 104…”