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Physicians’ Decision-Making Roles for an Acutely Unstable Critically and Terminally Ill Patient*

Uy, Jamie BS1; White, Douglas B. MD, MAS2,3; Mohan, Deepika MD, MPH2; Arnold, Robert M. MD3,4,6,7; Barnato, Amber E. MD, MPH, MS4,5

doi: 10.1097/CCM.0b013e318287f0dd
Clinical Investigations

Objectives: There is substantial variation in use of life sustaining technologies in patients near the end of life but little is known about variation in physicians’ initial ICU admission and intubation decision making processes. Our objective is to describe variation in hospital-based physicians’ communication behaviors and decision-making roles for ICU admission and intubation decisions for an acutely unstable critically and terminally ill patient.

Design: We conducted a secondary analysis of transcribed simulation encounters from a multi-center observational study of physician decision making. The simulation depicted a 78-year-old man with metastatic gastric cancer and life threatening hypoxia. He has stable underlying preferences against ICU admission and intubation that he or his wife will report if asked. We coded encounters for communication behaviors (providing medical information, eliciting preferences/values, engaging the patient/surrogate in deliberation, and providing treatment recommendations) and used a previously-developed framework to classify subject physicians into four –mutually-exclusive decision-making roles: informative (providing medical information only), facilitative (information + eliciting preferences/values + guiding surrogate to apply preferences/values), collaborative (information + eliciting + guiding + making a recommendation) and directive (making an independent treatment decision).

Setting: Simulation centers at 3 US academic medical centers.

Subjects: Twenty-four emergency physicians, 37 hospitalists, and 37 intensivists.

Measurements and Main Results: Subject physicians average 12.4 years (SD 9.0) since graduation from medical school. Of 98 physicians (39%), 38 physicians sent the patient to the ICU, and 9 of 98 (9%) ultimately decided to intubate. Most (93 of 98 [95%]) provided at least some medical information, but few explained the short-term prognosis with (26 of 98 [27%]) or without intubation (37 of 98 [38%]). Many (80 of 98 [82%]) elicited the patient’s intubation preferences, but few (35 of 98 [36%]) explored the patient’s broader values. Based on coded behaviors, we categorized 1 of 98 (1%) as informative, 48 of 98 (49%) as facilitative, 36 of 98 (37%) as collaborative, and 12 of 98 (12%) as directive; 1 of 98 (1%) could not be placed into a category. No observed physician characteristics predicted decision-making role.

Conclusions: The majority of the physicians played a facilitative or collaborative role, although a greater proportion assumed a directive role in this time-pressured scenario than has been documented in nontime-pressured ICU family meetings, suggesting that physicians’ roles may be context dependent.

1 Office of the Med-Dean, University of Pittsburgh School of Medicine, Pittsburgh, PA.

2 Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.

3 Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, PA.

4 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.

5 Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, PA.

6 Institute for Doctor-Patient Communication, University of Pittsburgh, Pittsburgh, PA.

7 UPMC Palliative and Supportive Institute, Pittsburgh, PA

*See also p. 1587.

Dr. Barnato received grants from the National Cancer Institute (R21CA139264, R21CA141093); Kornfeld Program in Bioethics and Patient Care, administered by the Greenwall Foundation; American Cancer Society (PEP-08-276-01-PC2); Jewish Healthcare Foundation; and Samuel and Emma Winters Foundation. Ms. Jamie Uy was supported by the Gleitsman Award from the Institute to Enhance Palliative Care, University of Pittsburgh School of Medicine. Dr. White was funded by a Greenwall Foundation Faculty Scholars award and by a grant from the National Institute on Aging (R01HL094553). The remaining authors have not disclosed any potential conflicts of interest.

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© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins