Differences Between Attendings’ and Fellows’ Perceptions of Futile Treatment in the Intensive Care Unit at One Academic Health Center

Abstract

Purpose Knowing when patients are too ill to benefit from intensive care is essential for clinicians to recommend aggressive or palliative care as appropriate. To explore prognostic ability among critical care fellows, the authors compared fellows’ and attendings’ assessments of futile critical care and evaluated factors associated with assessments. Method Thirty-six attendings and 14 fellows in intensive care units at the University of California, Los Angeles, were surveyed daily for 3 months (December 2011–March 2012) to identify patients perceived as receiving futile treatment. Frequencies of futile treatment assessments and reasons listed by attendings versus fellows were compared. Predictors of futile treatment assessments by provider type were assessed using multivariate probit models. Results Attendings made 6,897 assessments on 1,125 patients; fellows made 4,407 assessments on 773 patients. Fellows assessed 161 (20.8%) patients as receiving futile treatment, compared to attendings (123 [10.9%] patients, P < .001), and listed fewer reasons that treatment was futile (P < .001). Fellows were more likely to assess a patient as receiving futile treatment by the second day, whereas attendings took four days. Patients assessed as receiving futile treatment by fellows were less likely than patients so assessed by attendings to die in the hospital (51% vs. 68%, P = .003) and within 6 months (62% vs. 85%, P < .001). Conclusions Fellows made earlier assessments and judged more patients to be receiving futile treatment than attendings, and their assessments were less predictive of mortality, suggesting that assessment of treatment appropriateness develops with experience.

A systematic review defining non-beneficial and inappropriate end-of-life treatment in patients with non-cancer diagnoses: theoretical development for multi-stakeholder intervention design in acute care settings

“…This is illustrated by an online survey with open questions among 592 patients and relatives in the Netherlands which found that following the patient’s, as well as relatives’ wish, was commonly mentioned to describe appropriate care [ 64 ]. It was also notable that it can be considered appropriate when patient or family/guardian understands that a treatment is unlikely to succeed but chooses to attempt a curative or life-prolonging treatment anyway [ 64 – 66 ] ( n = 3). For instance, a survey in Japan among physicians and laypeople found that even if patients had sufficient information regarding a potential treatment, there was still a difference in judgements between patients and physicians due to different perspectives of the importance of medical information [ 65 ].…”

“…Adding complexity is the consideration of resource consumption and economic burden to the healthcare system [ 66 , 68 , 76 , 89 , 90 ]. This relates to contexts involving staff burnout and moral distress [ 75 , 91 – 94 ] that have been demonstrated to accompany decisions to treat when little or no hope of benefit exists.…”

Predicting the outcome of a comatose patient at the bedside

“…Much may be said for experience. Indeed, some studies suggest that seniority of staff boosts chances of survival, but careful assessment of all possible variables remains key 6 7. Additionally, before we prognosticate, we must consider all potential (including aggressive) treatments.…”

Futility and Patients Who Insist on Medically Ineffective Therapy

“…When compared with the fellows, the attending physicians were more accurate in their predictions and able to offer more reasons to support their assessment that treatment was futile. 39 One area on which many clinicians agree is that medical practices often are dictated by fears of litigation, which can greatly impact EOL decision making. Though legislation exists regarding medical futility and decision-making processes, clinicians still believe there is a lack of support.…”