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A Multicenter Study of the Causes and Consequences of Optimistic Expectations About Prognosis by Surrogate Decision-Makers in ICUs

White, Douglas B. MD, MAS1; Carson, Shannon MD2; Anderson, Wendy MD, MAS3; Steingrub, Jay MD4; Bird, Garrett MD5; Curtis, J. Randall MD, MPH6; Matthay, Michael MD7; Peterson, Michael MD8; Buddadhumaruk, Praewpannarai RN, MS9; Shields, Anne-Marie RN, MSN1; Ernecoff, Natalie MPH9; Shotsberger, Kaitlin RN, MSN10; Weissfeld, Lisa PhD11; Chang, Chung-Chou H. PhD9; Pike, Francis PhD12; Lo, Bernard MD13; Hough, Catherine L. MD, MSc14

doi: 10.1097/CCM.0000000000003807
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Objectives: Optimistic expectations about prognosis by surrogate decision-makers in ICUs are common, but there are few data about the causes and clinical consequences. Our objective was to determine the causes of optimistic expectations about prognosis among surrogates and whether it is associated with more use of life support at the end of life.

Design: Prospective, multicenter cohort study from 2009 to 2012.

Setting: Twelve ICUs from multiple regions of the United States.

Subjects: The surrogates and physicians of 275 incapacitated ICU patients at high risk of death.

Interventions: None.

Measurements and Main Results: Surrogates and physicians completed a validated instrument assessing their prognostic expectations for hospital survival. We determined the proportion of surrogates with optimistic expectations, defined as a prognostic estimate that was at least 20% more optimistic than the physician’s, then determined how frequently this arose from surrogates miscomprehending the physicians’ prognosis versus holding more hopeful beliefs compared with the physician. We used multivariable regression to examine whether optimistic expectations were associated with length of stay, stratified by survival status, and time to withdrawal of life support among nonsurvivors. Overall, 45% of surrogates (95% CI, 38–51%) held optimistic expectations about prognosis, which arose from a combination of misunderstanding the physician’s prognostic expectations and from holding more hopeful beliefs compared with the physician. Optimistic expectations by surrogates were associated with significantly longer duration of ICU treatment among nonsurvivors before death (β coefficient = 0.44; 95% CI, 0.05–0.83; p = 0.027), corresponding to a 56% longer ICU stay. This difference was associated with a significantly longer time to withdrawal of life support among dying patients whose surrogates had optimistic prognostic expectations compared with those who did not (β coefficient = 0.61; 95% CI, 0.16–1.07; p = 0.009).

Conclusions: The prevalent optimism about prognosis among surrogates in ICUs arises both from surrogates’ miscomprehension of physicians’ prognostications and from surrogates holding more hopeful beliefs. This optimism is associated with longer duration of life support at the end of life.

1Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

2Division of Pulmonary and Critical Care Medicine, UNC-Chapel Hill School of Medicine, Chapel Hill, NC.

3Division of Palliative Medicine, UCSF School of Medicine, San Francisco, CA.

4Division of Pulmonary and Critical Care, Department of Medicine, Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, MA.

5Department of Medicine, UCSF-Fresno School of Medicine, Fresno, CA.

6University of Washington School of Medicine, Seattle, WA.

7Division of Pulmonary and Critical Care, Department of Medicine, UCSF School of Medicine, San Francisco, CA.

8Division of Pulmonary and Critical Care, Department of Medicine, UCSF-Fresno School of Medicine, Fresno, CA.

9Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

10St. Clair Hospital, Pittsburgh, PA.

11The Statistics Collaborative, Washington, DC.

12Eli Lilly, Indianapolis, IN.

13Department of Medicine, UCSF School of Medicine, San Francisco, CA.

14Division of Pulmonary and Critical Care, Department of Medicine, University of Washington School of Medicine, Seattle, WA.

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).

Supported, in part, by grant from National Institutes of Health; National Heart, Lung, and Blood Institute grant R01HL094553.

Drs. White’s, Steingrub’s, Buddadhumaruk’s, Weissfeld’s, and Hough’s institution received funding from National Institutes of Health (NIH). Drs. White’s and Bird’s institutions received funding from National Heart, Lung, and Blood Institute (NHLBI) grant R01HL094553. Dr. White received funding from UptoDate. Drs. White, Carson, Anderson, Steingrub, Bird, Buddadhumaruk, Shields, Ernecoff, Weissfeld, Chang, and Hough received support for article research from the NIH. Drs. Carson’s, Anderson’s, Shields’s, and Ernecoff’s institutions received funding from the NHLBI. Dr. Carson’s institution received funding from Biomarck Pharmaceuticals. Dr. Bird received funding from Forrest Pharmaceuticals (speakers fees). Dr. Matthay’s institution received funding from Bayer Pharmaceuticals (Observational Study of Acute Respiratory Distress Syndrome [ARDS] grant), GlaxoSmithKline (Observational Studies of Sepsis), and he received funding from CS Behring (consultation on ARDS). The remaining authors have disclosed that they do not have any potential conflicts of interest.

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

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