Physicians’ Own Beliefs on Goals of Care Influence Presentation of Comfort Care Option to Patient Surrogates
Abstract & Commentary
By Betty Tran, MD, MS, Assistant Professor of Medicine, Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago. Dr. Tran reports no financial relationships relevant to this field of study.
This article originally appeared in the January 2013 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
Synopsis: During family discussions, physicians who believe more strongly that life support should be withdrawn are more likely to present the option of comfort care and describe its benefits.
Source: Schenker Y, et al. Association between physicians’ beliefs and the option of comfort care for critically ill patients. Intensive Care Med 2012;38:1607-1615.
This study conducted in five ICUs at two academic hospitals in San Francisco sought to describe how comfort care is presented to surrogates and if physicians’ beliefs on whether life support should be withdrawn are associated with the option of comfort care being presented. One hundred and five physician-family conferences were identified through the ICU nurses, but only 72 were included in the final analysis after excluding conferences in which the physician and/or family declined participation. Each conference was audiotaped and subsequently transcribed verbatim for analysis. The study team coded whether comfort care was presented as an option by the physician, what risks and benefits of comfort care were presented, and what other treatment options (unlimited intensive care or limited intensive care) were offered. Demographic information was collected on patients, surrogates, and physicians. Physicians were also asked immediately after the conference to grade how strongly they believed life support should be withheld or withdrawn prior to the family conference on a scale of 0 (not strongly at all) to 10 (extremely strongly). Coders were blinded to all the participants’ questionnaire responses.
The physician-family conferences occurred a mean of 10 days after ICU admission; on average, 60% of the ICU stay had elapsed at the time of the conference. Patients had a mean APACHE II score of 29 on the day of the conference, with the overall inpatient mortality rate being 72% (all due to withdrawal of life support). Comfort care was not presented as an option in 32 of 72 (44%) of the conferences; of these, 78% included only discussion of continued unlimited intensive care. In multivariate analyses, the only variable associated with the presentation of comfort care was the strength of the physicians’ belief that life support should be withdrawn (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.14-1.66; P = 0.01). In the 40 (56%) of 72 conferences in which comfort care was presented, there was an association between the strength of the physician’s belief that life support should be withdrawn and the number of unique benefits of comfort care that were discussed (OR 1.12, 95% CI 1.01-1.25; P = 0.04).
Commentary
In their clinical policy and consensus statements, the American College of Critical Care Medicine and American Thoracic Society support a shared decision-making model that includes surrogates, family members, and the health care team when the patient lacks full decision-making capacity. For example, for technical decisions regarding choice of antibiotics, surrogates overwhelmingly prefer physicians to make the final decision, but when it comes to life-sustaining treatment decisions, the extent to which the physician is involved is variable and can depend not only on surrogate preferences, but also the physician’s own professional judgment and ethics.1-3
Thus, depending on the context, although the authors cite their findings as surprising, their results can be viewed as fairly predictable. Physicians may be more likely to present and promote comfort care as an option in cases where they believe no other medical treatment is available or for patients who have a dismal prognosis from a prior underlying condition, such as metastatic cancer or chronic lung disease. On the other hand, physicians may be less likely to present comfort care options in situations they perceive to be potentially reversible. Alternatively, if patients or surrogates have previously expressed their wishes to continue aggressive care, physicians may be more reluctant to raise the option of comfort care. In these situations, the omission of comfort care as an option is not necessarily an oversight on the part of the physician, but may be a conscientious decision based on the clinical scenario. As the authors duly note, the context surrounding the decision not to present comfort care as an option is an important area for future research.
Furthermore, although the authors rightly argue that failure to present comfort care as an option based purely on physicians’ beliefs is problematic, the issue of how and when best to present this alternative to surrogates has yet to be answered. The notion that comfort care is “giving up” or “doing less” as opposed to “doing everything” will have to be quelled, and continual, open communication between physicians and surrogates will be necessary to foster trust in the families of critically ill patients and to understand their preferences in the decision-making process. These aims, in addition to improving clinician communication skills in discussing life-sustaining treatment decisions, will enhance the extent to which physicians can support and advise surrogates in the decision-making process.
References
1. Truog RD, et al. Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008;36:953-963.
2. Lanken PN, et al. An official American Thoracic Society clinical policy statement: Palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:912-927.
3. Johnson SK, et al. An empirical study of surrogates’ preferred level of control over value-laden life support decisions in intensive care units. Am J Respir Crit Care Med 2011;183:915-921.
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