A scenario-based, randomized trial of patient values and functional prognosis on intensivist intent to discuss withdrawing life support

Abstract

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.

Figure 1. Recruitment, randomization, and exclusion criteria

“No Response” is defined as never clicking the web link to the study survey in the invitation e-mail. “Not completed” means that the web link to the study survey was clicked, but not all survey questions were answered. “Not practicing” indicates that the physician selected “No” in response to the survey question: “Have you treated patients in the ICU setting in the last two years?”

Figure 2. Intensivist response to the question “Would you bring up the possibility of withdrawing life support with Mrs. X’s family?”

Study participants responded using a 5-point Likert scale containing: Definitely No, Probably No, Maybe, Probably Yes, and Definitely Yes. Probability of in-hospital mortality was calculated using the Mortality Probability Model II – 72 Hours (MPMII –72). Bars depict 95% confidence intervals for the proportion of intensivists selecting Maybe, Probably Yes, or Definitely Yes for plot on left and Probably Yes or Definitely yes for plot on right. The X-coordinates of over-lapping confidence intervals have been jittered to avoid overlap. Lines are loess curves generated using a bandwidth of 0.5.

Figure 3. Three-month, function prognosis as predicted by 210 intensivists

The 210 intensivists in the second experimental arm of the study (prognosis group) recorded estimates of the most likely 3-month, functional outcome for each of 10 scenarios using a scale with the options: 1) Able to live independently with no physical or cognitive decline from pre-ICU status, 2) Able to live independently with some physical and cognitive decline from pre-ICU status, 3) Dependent in at least one ADL and unable to live independently, 4) Dependent in all activities of daily living and unable to live independently, or 5) In-hospital death. Scenarios are displayed by MPMII-72 probability of in-hospital mortality from left to right.