Families' optimism often at odds with physicians' prognoses

Family members of intensive care patients are likely to be more optimistic about their loved ones' chances of survival, regardless of how a physician presents a grim prognosis.

That was the conclusion of a study that sought to identify the best way for doctors to communicate with families of the more than 5 million patients admitted to intensive care units in the U.S. annually.

Instead, researchers found that the method of communication mattered little in trying to align family members' opinions with physicians.

Such innate differences of opinion can have serious consequences, said Douglas B. White, MD, associate professor of critical care medicine and director of the Program on Ethics and Decision Making in Critical Illness at the University of Pittsburgh School of Medicine.

"The most important is that it likely will lead to families requesting ongoing life-sustaining treatment, when a palliative pathway might be more appropriate," said Dr. White, one of the study's authors. "The other thing that could come up is conflict between doctors and families."

Researchers surveyed 169 surrogate decision-makers of ICU patients at the University of California, San Francisco Medical Center between 2005 and 2008 after surrogates saw a 10-minute video of a simulated physician-family conference.

Eighty-six were shown videos in which the physician used qualitative phrases such as "it's very unlikely he will survive," while 83 were shown a video using a numeric explanation like "he has about a 10% chance of surviving," according to the study, posted online June 10 in the American Journal of Respiratory and Critical Care Medicine.

The survey asked for the surrogates' personal estimates of the patient's prognosis and their understanding of the physician's prognosis. Surrogates uniformly comprehended the physician's prognosis, but there were significant differences between their understanding of the doctor's opinion and personal estimates of the patient's prognosis.

Fifteen percent of surrogates thought the patient's condition was worse than the physician said, but 45% were more optimistic than the physician. "Surrogates on average estimated the patient was more than twice as likely to survive than the physician did," according to the study.

Being more pessimistic than the physician also creates challenges, because it means families may choose to forgo potentially beneficial therapies, said J. Randall Curtis, MD, MPH, professor and head of the section of pulmonary and critical care medicine at the University of Washington School of Medicine and Harborview Medical Center in Seattle.

The importance of trust

Another finding was that "less trust in physicians was associated with larger discrepancies," the study said.

Dr. Curtis is immediate past president of the American Thoracic Society and has studied surrogate decision-making in the ICU for 10 years. He said there is a growing awareness in critical care of the importance of providing support and building trust with family members.

"There may be a lot that goes into communication with family members other than just giving information," he said. "It is a difficult situation. Family members are under a lot of stress."

Dr. White said establishing relationships with patients' family members in an ICU setting is difficult because families are in crisis and often are meeting a physician for the first time. Also, ICU physicians typically work in shifts, so families may interact with multiple doctors. "Families can be quite overwhelmed," he said.

Dr. Curtis said there has been much debate on how best to communicate with families. He advocates using both numeric and qualitative language when talking to families to make a prognosis as clear as possible but said his focus will shift because of the study. He will be less dogmatic about trying to present the information in different ways, and instead will ask family members directly what would be most helpful for them to understand the situation.

Dr. White said there's no clear answer to how physicians can solve the disparity of opinions in critical care. It requires further research. "We don't really know how to improve this problem," he added.