Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients

Abstract

IMPORTANCE 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). DESIGN, SETTING, AND PARTICIPANTS 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. MAIN OUTCOMES AND MEASURES 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 AND RELEVANCE 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.

Numeracy and Interpretation of Prognostic Estimates in Intracerebral Hemorrhage Among Surrogate Decision Makers in the Neurologic ICU

“…Our findings are consistent with other studies showing a lack of concordance between prognostic estimates made by clinicians and prognostic estimates made by surrogate decision makers (11–13). Poor numeracy was independently associated with worse concordance, suggesting that an impaired understanding of the numeric statements provided by physicians contributes significantly to this discordance.…”

“…This is less likely to be the case in a survey-based study employing hypothetical patient scenarios, as the emotional component is reduced, and there is minimal enmeshment between the decision maker and patient (39). Surrogates can be subject to cognitive biases, including optimism bias, recall bias, focusing bias, and the better-than-average effect when making decisions on behalf of patients (11–13, 17, 40–42). Some of these cognitive biases may have played a role in the discordance noted within our study.…”

“…Poor numeracy (ability to understand and apply numeric information) may impair the ability of surrogates to understand and interpret the data provided (15, 16), with lower numeracy resulting in more discordance (11). Optimism bias further influences surrogates’ prognostic estimates (11–13, 17), and surrogates may be less able to accurately interpret numerical statements predicting a high likelihood of death (12). …”

Shared Decision Making in Neurocritical Care

“…There is an abundance of literature suggesting that patients with hemorrhagic stroke or severe traumatic brain injury may be subject to early, grave, and biased prognostications, sometimes leading to self-fulfilling prophecies 27–31 . Furthermore, it is likely that the prognostic discordance between surrogates and physicians observed in a mixed ICU population 32 is at least as prevalent in the neuroICU owing to the sudden nature of the patient’s grave illness. Physician prognostic bias as well as surrogate’s misunderstanding about prognosis may be mitigated by the use of a SDM intervention, such as a disease-specific DA in the neuroICU 3,6,13 .…”

How acceptable is paternalism? A survey-based study of clinician and nonclinician opinions on paternalistic decision making

“…Given important differences in how clinicians and nonclinicians approach decision making for critically ill patients (Anderson Cimino and Ernecoff 2015; Cai et al 2015; Thaler and Sunstein 2008) and how these groups differ in their interpretation of prognostic information (Zier et al 2012; White et al 2016), it is also likely that these two groups differ in their approach to paternalistic decision making. To explore these differences, we chose to focus on the opinions of the lay public (nonclinicians) and clinicians about medical decision making in the context of acute neurological injury, where the sudden onset of new deficits, the inability of the patient to participate in decisions, time pressures for decisions about acute treatments such as brain surgery, and the inherent uncertainty surrounding neurological recovery (Luce and White 2009) make decision making especially fraught.…”