Families' optimism often at odds with physicians' prognoses

A study finds that family members often disagree with doctors on an ICU patient's chances of survival, leading to conflicts over appropriate care.

By — Posted Aug. 2, 2010

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

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.

Back to top

External links

"A Randomized Trial of Two Methods to Disclose Prognosis to Surrogate Decision Makers in ICUs," American Journal of Respiratory and Critical Care Medicine, published online June 10 (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story