Saturday, November 10, 2007

Are intensivists prognostic pessimists?

An article appeared in the British Medical Journal suggesting that ICU clinicians have unwarranted prognostic pessimism that results in some patients, who might otherwise survive, being denied admission to ICU. In this study, clinicians were asked to estimate the likelihood of survival of patients with COPD and asthma exacerbations who required admission to ICU. The study found out that clinicians underestimated six-month survival by 13%. Sixty two percent of patients survived compared with the clinicians’ prediction of 49%.

  • To me this seems like pretty good prediction. But I’m, after all, just a lousy ICU clinician.
  • I have worked in both the UK and the US medical systems. My impression is that, if there is a tendency to unwarranted prognostic pessimism in the UK, there may be a tendency to unwarranted prognostic optimism in the US.

Clinician pessimism, according to the article, was particularly marked for the patients with the poorest clinician prognosis. Clinicians predicted a 180-day survival of around 3%, whereas the actual survival was 36%.

  • The most important question may not be whether the patients survived, but rather how they survived. If they survived with a good quality of life, then the poor prognostic prediction – prognostic pessimism - could have had dire consequences. If they survived with a miserable quality of life, choosing not to pursue ICU admission may have been appropriate.

  • Why may ICU clinicians be prognostic pessimists? Is this true for all clinicians? My experience is that surgeons are prognostic optimists. When I have expressed pessimism about a patient’s prognosis, my surgical colleagues have often pointed out that my seeing patients at their sickest biases my perspective. When patients recover, they often recover dramatically. When we discharge patients from the ICU, they are usually still debilitated. So, perhaps, as intensivists, our perspective is skewed.

A major concern about prognostic pessimism is that we are not uniform in our assessments. Many clinicians focus on different information, and this may lead them to form different conclusions. All ICU clinicians do not reach the same conclusions about a patient’s prognosis even when they are privy to the same information. This has been used to support the implementation of “objective outcome prediction models”. Such models, however, are also error prone as they work for populations BUT not for individuals.


One of the most poignant opinion pieces I have read appeared recently in the journal, JAMA. An experienced ICU clinician was confronted with a dreaded situation; his father had metastatic cancer and was critically ill. His condition was complicated by renal failure. The father and the physician’s family looked to him for guidance. The clinician confessed that being emotionally vested complicated his decision-making and may have affected the clarity of his thinking. After much deliberation, his father and his family, with his sanction, decided not to initiate dialysis. The father died. The ICU physician may at times second-guess this tough decision in moments of emotional turmoil. But, this decision was undoubtedly motivated by love and compassion, and required tremendous strength of character from all parties. In such difficult circumstances, it is vitally important that efforts are made to ensure that all family members are like-minded and agree with the chosen course of action.

Decisions regarding the pursuit of aggressive therapy versus palliative care must be addressed with patients and their families by physicians who are competent and experienced in end-of-life care as this will have a profound impact on both the quality of care delivered and effective use of limited hospital resources. A major problem is that regional culture plays an important part in end of life decision-making. Such cultural differences not only affect patients and their families but also the health care workers who make and carry out such decisions. This can lead to tension if there are cultural differences between physicians and patients’ families or among health care workers themselves.



Perspectives from a biased ICU Clinician:

  1. Sometimes withholding or withdrawing advanced life support is the most compassionate course.
  2. Quality of life, not just survival, should be considered in making decisions.
  3. It may be helpful to seek the opinion of a colleague who is not emotionally vested in the care of a patient.
  4. We should ask ourselves whether our judgment might be clouded by prognostic pessimism.
  5. Prognostic optimism may be a euphemism for fear of litigation or defensive medicine.
  6. For an optimistic perspective, always consult a surgeon.
  7. The right to a dignified death should be viewed as a fundamental human right, just as the right to a dignified life is.
  8. Unwarranted prognostic pessimism may lead to patients being denied life-saving interventions.
  9. Unwarranted prognostic optimism may lead to patients being denied a dignified death.
  10. Even the most insightful clinician may misjudge a patient’s prognosis. It may be better to err on the side of optimism than that of pessimism.

14 comments:

Anonymous said...

This is my first post I'd like to congratulate you for such a terrific quality forum!
Just thought this is a perfect way to introduce myself!

Sincerely,
Monte Phil
if you're ever bored check out my site!
[url=http://www.partyopedia.com/articles/barbie-party-supplies.html]barbie Party Supplies[/url].

Anonymous said...

[url=http://www.kfarbair.com][img]http://www.kfarbair.com/_images/_photos/photo_big8.jpg[/img][/url]

בית מלון [url=http://www.kfarbair.com]כפר בעיר[/url] - שירות חדרים אנחנו מציעים שירותי אירוח מיוחדים גם יש במקום שירות חדרים המכיל [url=http://www.kfarbair.com/eng/index.html]אחרוחות רומנטיות[/url] במחירים מפתיעים אשר יוגשו ישירות לחדרכם...

לפרטים נא גשו לאתר האינטרנט שלנו - [url=http://kfarbair.com]כפר בעיר[/url] [url=http://www.kfarbair.com/contact.html][img]http://www.kfarbair.com/_images/apixel.gif[/img][/url]

Anonymous said...

Infatuation casinos? ruminate on this advanced [url=http://www.realcazinoz.com]casino[/url] managing director and manufacture online casino games like slots, blackjack, roulette, baccarat and more at www.realcazinoz.com .
you can also stay our untrained [url=http://freecasinogames2010.webs.com]casino[/url] control at http://freecasinogames2010.webs.com and supersede in corporeal exhaustive currency !
another late-model [url=http://www.ttittancasino.com]casino spiele[/url] restraint of events is www.ttittancasino.com , because german gamblers, watch not busy online casino bonus.

Anonymous said...

Hello. My wife and I bought our house about 6 months ago. It was a foreclosure and we were able to get a great deal on it. We also took advantage of the 8K tax credit so that definitely helped. We did an extensive remodeling job and now I want to refinance to cut the term to a 20 or 15 year loan. Does anyone know any good sites for mortgage information? Thanks!

Mike

Anonymous said...

Hi,

My name is Eva.

I'm excited to be part of this large and growing forum of great people and thankyou all for making me feel welcome. I just joined today.

My special interests or skills are:
- HTML
- SEO
- Web design
- Internet business

I am happy to help others that need it and offer advice where possible :)

Anonymous said...

http://13dfgsdfg57.com/

Anonymous said...

Hello. And Bye. Thank you very much.

Anonymous said...

Hello. And Bye. Thank you very much.

Anonymous said...

even performing as slight with Sony Music and near Experience new albums or EP s out in the U. S. in 2012. [url=http://www.onlinecasinoburger.co.uk/]casino online[/url] uk online casino They Feature likewise fallen touch likelihood of Taking and losing. http://www.onlinecasinoburger.co.uk/

Anonymous said...

What i don't understood is in fact how you're no longer really
much more neatly-appreciated than you may be
right now. You're so intelligent. You understand therefore significantly in the case of this topic, made me individually imagine it from numerous numerous angles. Its like women and men aren't interested
until it's one thing to accomplish with Woman gaga! Your personal stuffs outstanding. All the time care for it up!

Visit my homepage - free weight loss programs

Anonymous said...

Wow! Finally I got a webpage from where I be able to in fact obtain valuable facts concerning my study
and knowledge.

Look into my webpage; rheumatoid arthritis facts

Anonymous said...

The quicker you can identify the problem, the quicker
you can fix it. Increased Contrast and Sharper Detail: "Relief Tint" computer clip on reading glasses
reduce violet and blue light providing increased contrast
in vision while preserving color. Simply starting or "booting"
your computer is enough to activate this nasty critter if your computer is infected.


My site may tinh

Anonymous said...

Their parents will believably telephone you the identical adjacent day begging improve for indisputable too. [url=http://www.l2merkell.com/foro/index.php?topic=392864.new#new]This Site[/url] Get the Facts A coalescency is when in under troika seconds, and - virtually unfathomably - 0-124 mph in under nine seconds. http://era-of-blade.ru/phpbb3/viewtopic.php?f=3&t=101410

Anonymous said...

Online casino slots are but as reliable as any to fund their casino accounts from their savings bank accounts, without the net receiver having to see their camber News report inside information. [url=http://ukpaydayloans.blog.co.uk/]payday loans uk[/url] payday loans Deposit Method acting BonusWhen you Select a particular down payment a sure key or key combination While the you are in the midst of a identical exciting secret plan. http://ukpaydayloans.blog.co.uk/