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A Scenario-Based, Randomized Trial of Patient Values and Functional Prognosis on Intensivist Intent to Discuss Withdrawing Life Support*

Turnbull, Alison E. DVM, MPH, PhD1,2,3; Krall, Jenna R. BA4; Ruhl, A. Parker MD2,3,5; Curtis, J. Randall MD, MPH6,7; Halpern, Scott D. MD, PhD8,9,10; Lau, Bryan M. ScM, MHS, PhD1; Needham, Dale M. FCA, MD, PhD2,3,11

doi: 10.1097/CCM.0000000000000227
Clinical Investigations

Objectives: To evaluate the effect of 1) patient values as expressed by family members and 2) a requirement to document patients’ functional prognosis on intensivists’ intention to discuss withdrawal of life support in a hypothetical family meeting.

Design: A three-armed, randomized trial.

Setting: One hundred seventy-nine U.S. hospitals with training programs in critical care accredited by the Accreditation Council for Graduate Medical Education.

Subjects: Six hundred thirty intensivists recruited via e-mail invitation from a database of 1,850 eligible academic intensivists.

Interventions: Each intensivist was randomized to review 10, online, clinical scenarios with a range of illness severities involving a hypothetical patient (Mrs. X). In control-group scenarios, the patient did not want continued life support without a reasonable chance of independent living. In the first experimental arm, the patient wanted life support regardless of functional outcome. In the second experimental arm, patient values were identical to the control group, but intensivists were required to record the patient’s estimated 3-month functional prognosis.

Measurements and Main Results: Response to the question: “Would you bring up the possibility of withdrawing life support with Mrs. X’s family?” answered using a five-point Likert scale. There was no effect of patient values on whether intensivists intended to discuss withdrawal of life support (p = 0.81), but intensivists randomized to record functional prognosis were 49% more likely (95% CI, 20–85%) to discuss withdrawal.

Conclusions: In this national, scenario-based, randomized trial, patient values had no effect on intensivists’ decisions to discuss withdrawal of life support with family. However, requiring intensivists to record patients’ estimated 3-month functional outcome substantially increased their intention to discuss withdrawal.

Supplemental Digital Content is available in the text.

1Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.

2Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins Medicine, Baltimore, MD.

3Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

4Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.

5Critical Care Medicine Department, National Institutes of Health, Bethesda, MD.

6Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA.

7Palliative Care Center of Excellence, University of Washington School of Medicine, Seattle, WA.

8Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

9Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

10Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

11Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD.

* See also p. 1560.

All authors contributed to the conception and design of the study. Dr. Turnbull and Ms. Krall analyzed the data. Dr. Turnbull drafted the article. All authors contributed to the interpretation of analyses, critically revised the article for important intellectual content, and gave final approval of the article version to be published. Dr. Turnbull is responsible for the overall content as guarantor.

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 website (http://journals.lww.com/ccmjournal).

Dr. Turnbull received support for article research from the National Institutes of Health (NIH) (supported by a postdoctoral training grant from the National Institute on Aging, T32-AG000247). Dr. Turnbull is supported by the Johns Hopkins University Sommer Scholars Program. Dr. Krall received grant support from the National Institute on Aging (T32-AG000247) and received support for article research from the NIH (T32-AG000247). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: turnbull@jhmi.edu

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins