Physicians’ Decision-Making Roles for an Acutely Unstable Critically and Terminally Ill Patient*

Abstract

Background 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. Objective 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). Subjects 24 emergency physicians, 37 hospitalists, and 37 intensivists from 3 US academic medical centers. Results Subject physicians average 12.4 (SD 9.0) years since graduation from medical school. 38/98(39%) physicians sent the patient to the ICU, and 9/98(9%) ultimately decided to intubate. Most (93/98 (95%)) provided at least some medical information, but few explained the short-term prognosis with (26/98 (27%)) or without intubation (37/98 (38%)). Many (80/98 (82%)) elicited the patient's intubation preferences, but few (35/98 (36%)) explored the patient's broader values. Based on coded behaviors, we categorized 1/98 (1%) as informative, 48/98 (49%) as facilitative, 36/98 (37%) as collaborative, and 12/98 (12%) as directive; 1/98 (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 non-time pressured ICU family meetings, suggesting that physicians’ roles may be context-dependent.

Talking With Parents About End-of-Life Decisions for Their Children

“…[39][40][41][42][43][44] What our study adds is the insight that parents appreciated receiving this detailed information, as evidenced by their reactions and their questions in return. It may be postulated that the provision of relevant information helps parents to grasp what is happening to their child and regain some feeling of control.…”

The Language of End-of-Life Decision Making: A Simulation Study

“…While studies of shared decision making at the end of life have focused on the content of communication, 4,5,14 less is known about the language used by physicians in these discussions. A recent study by Dieltjens et al evaluating conversations between physicians and patients requesting physician-assisted suicide in the Netherlands 15 analyzed communication style at the level of grammatical expression.…”

An Observational Study of Decision Making by Medical Intensivists

“…Indeed, the physician's identity explained a greater proportion of the variance in decisions made per patient than any patient characteristic. Prior studies have also noted variation in physician decision making and practice patterns with regard to such decisions as ICU admission, intubation, and withdrawal of life-sustaining therapy (22)(23)(24). Other single-center studies have shown that physician-attributable differences in care provision account for significant variation in ICU spending and in ICU-based limitations on life support (24,25).…”