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Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients
Open accessAbstract
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.
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“their own prognostic estimates may also have served as “illocutionary acts”—that is, expressions distinct from comprehension with which they intended to express positive attitude, optimism, or faith; to highlight patients’ unrecognized qualities of resilience; or to counter clinicians’ pessimism (15, 34–36).”
From Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation (2019) · cites this paper as [15]
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“Ineffective communication can result in the default provision of aggressive life support, which may conflict with patient preferences (15)”
From Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation (2019) · cites this paper as [15]
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Metadata
- Authors
- White, D. B., Ernecoff, N., Buddadhumaruk, P., Hong, S., Weissfeld, L., Curtis, J. R., Luce, J. M., & Lo, B.
- Affiliations
- University of Pittsburgh (US)
- Statistics Collaborative (US)
- University of Washington (US)
- University of California, San Francisco (US)
- Corresponding author
- White, Douglas B.
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2016-05-17
- Volume
- 315
- Issue
- 19
- Pages
- 2086
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2407608263
- Cited by
- 232
- References
- 39
- Citations by year
- 2026: 15 · 2025: 15 · 2024: 21 · 2023: 28 · 2022: 17 · 2021: 28 · 2020: 31 · 2019: 24 · 2018: 25 · 2017: 20 · 2016: 7
- FWCI
- 25.12
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health
- National Heart, Lung, and Blood Institute (R01HL094553)
- National Center for Research Resources (KL2RR024130)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Health Professions › General Health Professions › Ethics in medical practice
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Family and Patient Care in Intensive Care Units
- Keywords
- prognosis, surrogate decision makers, critically ill patients, intensive care unit, physician communication, end-of-life decisions, prognostic accuracy, advance care planning, physician-patient communication
- MeSH terms
- Adult, Aged, Attitude, Culture, Decision Making, Female, Humans, Intensive Care Units, Male, Middle Aged, Physicians, Probability, Prognosis, Terminal Care, Critical Illness, Proxy, Comprehension, Dissent and Disputes, Qualitative Research
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