Thursday, April 24, 2014

What pushes doctors to talk about withdrawal of life sustaining treatments?




What changes an ICU doctors intention to discuss withdrawal of life support in a family meeting? An interesting study published this month argues that a doctors willingness to discuss withdrawal of life support depends on how sick the patient is, but not necessarily what the patient’s values are in regards to functional recovery.  Interestingly, it also depends on whether doctors are required to record the patient’s most likely 3-month functional outcome before deciding whether to discuss withdrawal of life support.

The Study

The study, by Alison Turnbull (who also on twitter @vitaincerta) and colleagues, was a three-armed randomized control trial of 630 academic intensivists recruited via e-mail invitation. Each of these intensivists reviewed a single hypothetical patient across 10 different scenarios representing a wide range of illness severities that changed the probability of in-hospital mortality (all of which included that the patient was mechanically ventilated for the past 48 hours). The intensivisits were randomized three different groups, all of which had the identical 10 scenarios except for the following differences:

  • In the control-arm, the family members believed that patient did not want continued life support without a reasonable chance of independent living in her own home. 
  • In the first experimental arm, the patient was a “fighter” and would want life-sustaining therapy even if her best possible outcome is transfer to a nursing home where she would receive help with her activities of daily living 
  • In the second experimental arm, the patient values were identical to the control group, but intensivists were required to record the patient’s estimated 3-month functional prognosis.

After each scenario, the intensivisits were then asked to response to the following question: “Would you bring up the possibility of withdrawing life support with Mrs. X’s family?” using a five-point Likert scale.

What they found:

Values made little difference.
It didn't really mater what the patient's values were regarding willingness to continue life support based on functional recovery, intensivists would or wouldn’t discuss withdrawal of life support mainly based on the severity of illness. For instance, the proportion of intensivists in the control or first experimental arm that would probably or definitely discuss withdrawal of life support ranged from about 4% for the scenario with the lowest predicted mortality to 70-75% in the scenario with highest predicted mortality (Fig. 2).

Documenting Prognosis did
In every scenario, the proportion of doctors intending to discuss withdrawal of life sustaining treatments was greatest in the group that was randomized to document functional prognosis before making a decision on whether or not they will discuss withdrawal.   This was not significant though for the two scenarios in which the probability of in-hospital death was the lowest and the last two scenarios where the probability of in-hospital death was the greatest.   As the authors state in the article, this would suggest the impact of requiring one to record a 3-month functional outcome was most important in scenarios where the patient to survived, but become dependent in ADLs.

Take home points: 

I'm still trying to digest this article's ramifications, as their is a whole lot of decision making psychology that seems to be taking place here.  One that was discussed in the article was the focusing effect.  If you want people to base decisions on a particular attribute, have them think about that attribute before any decision is made. So, if you want doctors to pay attention to the goals of the patient when deciding whether to discuss withdrawal of care, especially when that goal is to stop life support if there was no reasonable chance of living independently, then ask them to write down what they think the patient’s functional prognosis is in three months.

The other thing that seems clear that doctors make decisions about when to talk about withdrawal of life sustaining treatments based on the severity of illness, which is consistent to what we see in real life practice.  If patients are likely to survive, its unlikely that doctors will discuss withdrawal. If they are likely to die in the hospital, its likely that doctors will discuss withdrawal.  If there is a greater amount of uncertainty around prognosis, then taking time to think about longer-term functional prognosis, not just survival, can influence doctors to talk about withdrawal of life sustaining treatments.

by: Eric Widera (@ewidera)

1 comment:

Jennifer Brokaw said...

I wonder if physicians would comply with a requirement to document likely 3 month functional status without a direct request from the patient's surrogate? Seems to me that the answer here lies in disseminating this information to patients and their surrogates, not necessarily to health care providers....