Chest
Volume 136, Issue 1, July 2009, Pages 110-117
Journal home page for Chest

Original Research
Critical Care Medicine
Surrogate Decision Makers' Responses to Physicians' Predictions of Medical Futility

https://doi.org/10.1378/chest.08-2753Get rights and content

Background

Although physicians sometimes use the futility rationale to limit the use of life-sustaining treatments, little is known about how surrogate decision makers view this rationale. We sought to determine the attitudes of surrogates of patients who are critically ill toward whether physicians can predict futility and whether these attitudes predict surrogates' willingness to discontinue life support when faced with predictions of futility.

Methods

This multicenter, mixed qualitative and quantitative study took place at three hospitals in California from 2006 to 2007. We conducted semistructured interviews with surrogate decision makers for 50 patients who were critically ill and incapacitated that addressed their beliefs about medical futility and inductively developed an organizing framework to describe these beliefs. We used a hypothetical scenario with a modified time-trade-off design to examine the relationship between a patient's prognosis and a surrogate's 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.

Results

Sixty-four percent of surrogates (n = 32; 95% confidence interval [CI], 49 to 77%) expressed doubt about the accuracy of physicians' futility predictions, 32% of surrogates (n = 16; 95% CI, 20 to 47%) elected to continue life support with a < 1% survival estimate, and 18% of surrogates (n = 9; 95% CI, 9 to 31%) elected to continue treatment when the physician believed that the patient had no chance of survival. Surrogates with religious objections to the futility rationale (n = 18) were more likely to request continued life support (odds ratio, 4; 95% CI, 1.2 to 14.0; p = 0.03) than those with secular or experiential objections (n = 15; odds ratio, 0.95; 95% CI, 0.3 to 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.

Section snippets

Materials and Methods

Between June 2006 and March 2007, we conducted a multicenter, mixed qualitative and quantitative study in three hospitals in California, including a Veterans Affairs hospital, a tertiary academic hospital, and a public county hospital. All study procedures were approved by the institutional review board at each participating hospital.

Study investigators identified eligible surrogates of patients who were critically ill by screening 1 day per week at each institution with a systematic sampling

Participant Characteristics

Of 58 eligible surrogates, 50 were included in the study, for an enrollment rate of 86%. Their demographic characteristics are described in Table 2. For nine patients, we enrolled two individuals who indicated that they were sharing responsibilities for surrogate decision making; for four patients, three individuals indicating that they were sharing responsibility were enrolled into the study. Table 3 describes the patients' demographic characteristics.

Surrogates' Attitudes About Predicting Physiologic Futility

Sixty-four percent of surrogates expressed

Discussion

Our findings provide new insight about the perspectives of surrogate decision makers on the medical futility rationale and point to practical considerations that may help to refine how physicians approach discussions about futility with surrogates. Most surrogates we interviewed were reluctant to immediately accept physicians' predictions of medical futility. We identified several explanations for this finding, including beliefs that individual physicians' predictions may be unreliable, a need

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    This project was supported by a grant from the University of California, Berkeley-University of California, San Francisco Joint Medical Program (Mr. Zier), a grant from the University of California, San Francisco Dean's Office Medical Student Research Program (Mr. Zier), and a grant from the National Center for Research Resources [KL2 RR024130], a component of the National Institutes of Health and the National Institutes of Health Roadmap for Medical Research (Dr. White). Dr. White is also supported by a grant from the Greenwall Foundation Faculty Scholars Program.

    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

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