Surrogate Decision-Makers' Perspectives on Discussing Prognosis in the Face of Uncertainty

Evans, Leah R.; Boyd, Elizabeth A.; Malvar, Grace; Apatira, Latifat; Luce, John M.; Lo, Bernard; White, Douglas B.

doi:10.1164/rccm.200806-969oc

Cited by 218 publications

(156 citation statements)

References 29 publications

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“…(13) Family members value information about diagnosis, prognosis, and treatment alternatives even when outcomes are unclear. (12,30,34) Our study has limitations worth noting. Although our cohort was enrolled consecutively from a diverse group of ICUs, the findings of a single center study may not reflect the experience of other medical centers.…”

Section: Discussionmentioning

confidence: 95%

“…However, physicians' avoidance of discussing prognosis conflicts with surrogates' wishes for disclosure of these estimates, even when the outcome is indefinite. (30) Other factors also could have represented barriers to surrogate-physician alignment of expectations including surrogates' numeracy, education level, language and cultural differences; the high prevalence of surrogate psychological and financial distress suffered during the ICU care of their loved one; and the multiple provider ICU environment. (26) Overall, these summed deficiencies in the surrogate-physician interaction likely heightened the general sense of uncertainty in the decision making process surrounding the provision of prolonged mechanical ventilation.…”

Section: Discussionmentioning

confidence: 99%

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Expectations and outcomes of prolonged mechanical ventilation

Cox¹

2010

Critical Care Medicine

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Objective: Prolonged mechanical ventilation (PMV) provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the PMV decision making process could provide an explanation to this phenomenon. Therefore, we aimed to compare PMV decision makers' expectations for long-term patient outcomes with prospectively observed outcomes.Design, Setting, and Patients: 126 patients undergoing PMV, their surrogates, and their intensive care unit physicians were enrolled consecutively (total n=378) at an academic medical center between April 2006 and April 2007 and followed prospectively for one year. Measurements:Participants were interviewed at the time of tracheostomy placement about their expectations for one-year patient survival, functional status, and quality of life. These expectations were then compared to observed one-year outcomes measured with validated questionnaires.Results: One-year follow up was 100%, with the exception of patient death or cognitive inability to complete interviews. At one year, only 11 (9%) patients were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for one-year patient survival (117 [93%]), functional status (90 [71%]), and quality of life (105 [83%]). In contrast, fewer physicians described high expectations for survival (54 [43%]), functional status (7 [6%]), and quality of life (5 [4%]). Surrogate-physician pair concordance in expectations was poor (all κ<0.08), as was their accuracy in outcome prediction (range 23-44%). Just 33 (26%) surrogates reported that physicians discussed what to expect for patients' likely future survival, general health, and caregiving needs. Conclusions:One-year patient outcomes for PMV patients were significantly worse than expected by patients' surrogates and physicians. Lack of prognostication about outcomes, discordance between

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Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%

Expectations and outcomes of prolonged mechanical ventilation

Cox¹

2010

Critical Care Medicine

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“…One very important strategy that should be implemented in every health care institution is proactive communication that makes clear to patients and surrogates the limitations of medical technology as well as any relevant policies in place regarding such situations. [6][7][8][9][10][11][12][13][14][15] This strategy may prevent some cases from reaching points of intractable conflict but most likely not all cases. For cases that reach these levels of contention, one could take a paternalistic view, in which the view of the physician and the health care team, based on an assumption of technical expertise, should be ultimately authoritative.…”

Section: The Concept Of Medical Futilitymentioning

confidence: 99%

The Need for an Effective Process to Resolve Conflicts Over Medical Futility: A Case Study and Analysis

Olmstead

Dahnke

2016

Critical Care Nurse

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The issue of medical futility requires a well-defi ned process in which both sides of the dispute can be heard and a resolution reached in a fair and ethical manner. Procedural approaches to medical futility cases provide all parties involved with a process-driven framework for resolving these disputes. Medical paternalism or the belief in the absolute rightness of the medical model will not serve to resolve these disputes. Although medical futility is fi rst determined by medicine, in order for the determination to meet legal criteria, it must be subject to review. The hope is that through a review process that meets legal criteria, the issue can be resolved without the need for court proceedings. If resolution cannot be obtained through this process, surrogates still have the right to seek court intervention. This issue is of relevance and importance in critical care nursing because of the role and position of critical care nurses, who have direct contact with patients and patients' families, the potential for moral distress in cases of possibly futile treatment, and the expanding roles of nurses, including critical care nurses and advanced practice nurses, in management and policy development. (Critical Care Nurse. 2016;36[6]:13-23) M rs J, an 88-year-old woman with an admitting diagnosis of change in mental status, originally on a nonmonitored medical surgical unit, was a full code. During her stay in the hospital, she had pneumonia develop. Mrs J underwent cardiopulmonary resuscitation (CPR) several times and was transferred to the intensive care unit, back to the medical surgical unit, then to an intermediate care unit, and back to the intensive care unit. During the last CPR attempt, Mrs J was intubated and became ventilator dependent. During her admission, Mrs J had been deemed not competent to make her own decisions by

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“…ICU physicians are hampered in that they frequently rotate on and off service; even assuming a semiopen or closed administrative model, 18 they frequently direct a patient's care for only a few days to a week -an often inadequate duration of time to build sufficient rapport with a patient and family. SICU nurses could direct palliative care discussions; however, previous studies note that patients want prognostic information from physicians 32 and even cite physicians to have an obligation to convey this information. 33 Moreover, each of the above scenarios presumes that the surgeon, intensivist, and/or SICU nurse have the desire and skill set to adequately conduct palliative care related meetingsa presumption that some experts question.…”

Section: Cultural Barriersmentioning

confidence: 99%

Nurse-Perceived Barriers to Effective Communication Regarding Prognosis and Optimal End-of-Life Care for Surgical ICU Patients: A Qualitative Exploration (314-A)

Aslakson

Wyskiel²,

Thornton³

et al. 2011

Journal of Pain and Symptom Management

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Background: Integration of palliative care for intensive care unit (ICU) patients is important but often challenging, especially in surgical ICUs (SICUs), in part because many surgeons equate palliative care with terminal care and failure of restorative care. SICU nurses, who are key front-line clinicians, can provide insights into barriers for delivery of optimal palliative care in their setting. Methods: We developed a focus group guide to identify barriers to two key components of palliative careoptimal communication regarding prognosis and optimal end-of-life care-and used the tool to conduct focus groups of nurses providing bedside care in three SICUs at a tertiary care, academic, inner city hospital. Using content analysis technique, responses were organized into thematic domains that were validated by independent observers and a subset of participating nurses. Results: Four focus groups included a total of 32 SICU nurses. They identified 34 barriers to optimal communication regarding prognosis, which were summarized into four domains: logistics, clinician discomfort with discussing prognosis, inadequate skill and training, and fear of conflict. For optimal end-of-life care, the groups identified 24 barriers in four domains: logistics, inability to acknowledge an end-of-life situation, inadequate skill and training, and cultural differences relating to end-of-life care. Conclusions: Nurses providing bedside care in SICUs identify barriers in several domains that may impede optimal discussions of prognoses and end-of-life care for patients with surgical critical illness. Consideration of these perceived barriers and the underlying SICU culture is relevant for designing interventions to improve palliative care in this setting.

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Surrogate Decision-Makers' Perspectives on Discussing Prognosis in the Face of Uncertainty

Abstract: The majority of surrogates of patients that are critically ill want physicians to disclose their prognostic estimates even if they cannot be certain they are correct. This stems from surrogates' belief that prognostic uncertainty is simultaneously unavoidable and acceptable.

Cited by 218 publications

References 29 publications

Expectations and outcomes of prolonged mechanical ventilation

Expectations and outcomes of prolonged mechanical ventilation

The Need for an Effective Process to Resolve Conflicts Over Medical Futility: A Case Study and Analysis

Nurse-Perceived Barriers to Effective Communication Regarding Prognosis and Optimal End-of-Life Care for Surgical ICU Patients: A Qualitative Exploration (314-A)

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