Surrogate Decision Makers.
Chest. 2009 Mar 24;
Authors: Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, White DB
Rationale Although the futility rationale is sometimes used by physicians to limit the use of life sustaining treatments, little is known about how surrogate decision-makers view the futility rationale. Objectives We sought to determine 1) the attitudes of surrogates of critically ill patients about whether physicians can predict futility and 2) whether these attitudes predict surrogates' willingness to discontinue life support when faced with predictions of futility. Design Multi-center, mixed qualitative and quantitative study at three California hospitals in from 2006 to 2007. Subjects Surrogate decision-makers of 50 incapacitated, critically ill patients. Methods We conducted semi-structured interviews with surrogates addressing their beliefs about medical futility and inductively developed an organizing framework to describe these beliefs. We used a hypothetical scenario with a modified time-tradeoff design to examine the relationship between a patient's prognosis and surrogates' willingness to withdraw life support. We used a mixed effects regression model to examine the association between surrogates' attitudes about futility and their willingness to limit life support in the face of a very poor prognosis. Validation methods included the use and integration of multiple data sources, multidisciplinary analysis, and member checking. Main results 64% (32/50; 95% CI: 49-77%) of surrogates expressed doubt about the accuracy of physicians' futility predictions. 32% (16/50; 95% CI: 20-47%) elected to continue life support with a < 1% survival estimate and 18% (9/50; 95% CI: 9-31%) elected to continue treatment when the physician felt there was no chance of survival. Surrogates with religious objections to the futility rationale (n = 18) were more likely to request continued life support (OR = 4; 95% CI: 1.2-14.0; p = 0.03), whereas those with secular or experiential objections (n = 15) were not (OR = 0.95; 95% CI: 0.3-3.4; p = 0.90). Conclusions Doubt about physicians' ability to predict medical futility is common among surrogate decision-makers. The nature of the doubt may have implications for responding to conflicts about futility in clinical practice.
PMID: 19318665 [PubMed - as supplied by publisher]