July 1, 2010

Families Of Critically Ill Distrust Doctors’ Prognosis

A new study finds that families of people who are critically ill may have a more hopeful view their loved one's condition than do doctors, even when doctors provide survival estimates.

The study is not the first to show that doctors and family members often differ in their opinions about survival probabilities of critically ill patients, raising doubts about whether doctors are effectively communicating prognoses.

Some experts say doctors should provide specific numerical estimates of a patient's survival odds, instead of qualitative estimates such as "not likely" or "very unlikely".

In the current study, researchers examined whether numeric and qualitative approaches differed in their effects on families' viewpoints.

The scientists had 169 family members of patients treated in one ICU watch videos portraying a doctor discussing a critically ill patient's prognosis with the family.

Half of the family members viewed a video depicting a scenario in which the doctor told the family their relative was "very unlikely" to survive, and "very likely" to die.  The doctor in the video also said that if the patient did survive, he would probably require a ventilator.

The other family members watched a video with the same scenario, with the exception that the doctor said the patient had a 10 percent chance of survival and a 90 percent chance of dying.

In both scenarios, the families came away with a more positive view of the hypothetical patient's prognosis than the doctor in the video had provided.

In one instance, study participants gave an average survival estimate of 26 percent after watching a video in which doctor said survival was "very unlikely."

And even after viewing the video in which the doctor gave a 10 percent survival probability, the participants still said the patient had, on average, a 22 percent chance of living.

"The key finding is that many families don't take physicians' estimates at face value," said study director Dr. Douglas White of the University of Pittsburgh Medical Center during an interview with Reuters.

The study's findings suggest that communicating with families is not simply a matter of giving numeric, rather than quantitative, estimates of the chances of survival.

However, the way in which doctors communicate with families is still important.  And it may be that ICU doctors need to give less information to family members, to avoid overwhelming them during a time of duress, Dr. White told Reuters.

Doctors might also try to explicitly ask family members if they understood the information they were given, Dr. White added.

Another critical issue is trust, since ICU doctors are neither the patient's nor family's primary care physician, meaning family members are often in a position of having to trust the judgment of someone they don't know.

Indeed, study participants who reported relatively less trust in doctors were more likely to disagree with the doctor's prognosis estimate in the video.

It is not yet clear precisely how ICU doctors can best establish trust between themselves and family members in such a short time and under such stressful situations, Dr. White said.

Research indicates that families consider a number of issues when it comes to their opinions of a loved one's chances of survival. 

In fact, in a previous study White and his colleagues found that family members of critically sick ICU patients rarely relied on a doctor's prognostication alone.

Instead, they frequently considered their own perceptions of their loved one's strength, "will to live", history of overcoming illness, as well as their own faith in a higher power.

Dr. White's current study did not examine whether differences between doctors' and family members' survival estimates might affect families' decisions on whether to continue life support.  But White cited previous research that supports this idea.

Research finds that doctors tend to be "fairly accurate" when estimating the general odds of whether patients in a given situation will survive to hospital discharge.  However, they are not as skilled in predicting whether any a particular patient will live or die, Dr. White said.

There is an "inherent uncertainty in medicine," he said, and doctors need to clearly communicate that to family members.

The study was published online in the American Journal of Respiratory and Critical Care Medicine, June 10, 2010.


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