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A randomized trial of the effect of patient race on physicians' intensive care unit and life-sustaining treatment decisions for an acutely unstable elder with end-stage cancer*

Barnato, Amber E. MD, MPH, MS, FACPM; Mohan, Deepika MD, MPH; Downs, Julie PhD; Bryce, Cindy L. PhD; Angus, Derek C. MD, MPH, FCCM; Arnold, Robert M. MD

Critical Care Medicine:
doi: 10.1097/CCM.0b013e3182186e98
Clinical Investigations
Abstract

Objectives: To test whether hospital-based physicians made different intensive care unit and life-sustaining treatment decisions for otherwise identical black and white patients with end-stage cancer and life-threatening hypoxia.

Design: We conducted a randomized trial of the relationship between patient race and physician treatment decisions using high-fidelity simulation. We counterbalanced the effects of race and case by randomly alternating their order using a table of random permutations. Physicians completed two simulation encounters with black and white patient simulator patients with prognostically identical end-stage gastric or pancreatic cancer and life-threatening hypoxia and hypotension, followed by a self-administered survey of beliefs regarding treatment preferences by race. We conducted within-subjects analysis of each physician's matched-pair simulation encounters, adjusting for order and case effects, and between-subjects analysis of physicians' first encounter, adjusting for case.

Setting: Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh, Pennsylvania.

Subjects: Thirty-three hospital-based attending physicians, including 12 emergency physicians, eight hospitalists, and 13 intensivists from Allegheny County, Pennsylvania.

Intervention: Race of patient simulator.

Measurements and Main Results: Measurements included physician treatment decisions recorded during the simulation and documented in the chart and beliefs about treatment preference by race. When faced with a black vs. a white patient, physicians did not differ in their elicitation of intubation preferences (within-subject comparison, 28/32 [88%] vs. 28/32 [88%]; p = .589; between-subject comparison, 13/17 [87%] vs. 13/17 [76%]; p = .460), intensive care unit admission (within-subject comparison, 14/32 [44%] vs. 12/32 [38%]; p = .481; between-subject comparison, 8/15 (53%) vs. 7/17 (41%); p = .456), intubation (within-subject comparison, 5/32 [16%] vs. 4/32 [13%]; p = .567; between-subject comparison: 1/15 [7%] vs. 4/17 [24%]; p = .215), or initiation of comfort measures only (within-subject comparison: 16/32 [50%] vs. 19/32 [59%]; p = .681; between-subject comparison: 6/15 [40%] vs. 8/17 [47%]; p = .679). Physicians believed that a black patient with end-stage cancer was more likely than a similar white patient to prefer potentially life-prolonging chemotherapy over treatment focused on palliation (67% vs. 64%; z = −1.79; p = .07) and to want mechanical ventilation for 1 wk of life extension (43% vs. 34%; z = −2.93; p = .003), and less likely to want a do-not-resuscitate order if hospitalized (51% vs. 60%; z = 3.03; p = .003).

Conclusions: In this exploratory study, hospital-based physicians did not make different treatment decisions for otherwise identical terminally ill black and white elders despite believing that black patients are more likely to prefer intensive life-sustaining treatment, and they grossly overestimated the preference for intensive treatment for both races.

Author Information

From the Center for Research on Health Care (AEB, CLB, RMA), University of Pittsburgh, Pittsburgh, PA; Division of General Internal Medicine (AEB, RMA), Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Health Policy Management (AEB, CLB), Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory (AEB, DM, DCA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Institute to Enhance Palliative Care (RMA), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA; Department of Critical Care Medicine (DM, DCA), University of Pittsburgh, Pittsburgh, PA; Department of Social and Decision Sciences (JD), Carnegie Mellon University, Pittsburgh, PA.

Supported, in part, by American Cancer Society (PEP-08-276-01-PC2) and National Cancer Institute (R21 CA139264).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's web site (www.ccmjournal.com).

Drs. Barnato, Mohan, Downs, Bryce, and Arnold received funding from the NIH. Dr. Angus has not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: aeb2@pitt.edu

© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins