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Surrogate Decision Makers' Interpretation of Prognostic Information: A Mixed-Methods Study

Lucas S. Zier, MD, MS; Peter D. Sottile, MD; Seo Yeon Hong, MBA; Lisa A. Weissfield, PhD; and Douglas B. White, MD, MAS
[+] Article, Author, and Disclosure Information

Acknowledgment: The authors thank Baruch Fischhoff, PhD, Department of Social and Decision Sciences, Carnegie Mellon University, for thoughtful comments on earlier drafts of this manuscript.

Grant Support: By grants from the National Heart, Lung, and Blood Institute (R01HL094553), the Greenwall Foundation, and the University of California Berkeley–University of California San Francisco Joint Medical Program.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2047.

Reproducible Research Statement:Study protocol: Available from Dr. White (e-mail, mailto:whitedb@upmc.edu). Statistical code and data set: Available to other investigators or approved individuals through written agreement by contacting Dr. White (e-mail, mailto:whitedb@upmc.edu).

Requests for Single Reprints: Douglas B. White, MD, MAS, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace Street, Scaife Hall, Room 608, HPU010604, Pittsburgh, PA 15261; e-mail, mailto:whitedb@upmc.edu.

Current Author Addresses: Drs. Zier and Sottile: Department of Internal Medicine, University of California, San Francisco, 505 Parnassus Avenue, Room 987, San Francisco, CA 94143-0119.

Ms. Hong and Dr. Weissfield: Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, 305 Parran Hall, 130 DeSoto Street, Pittsburgh, PA 15261.

Dr. White: Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace Street, Scaife Hall, Room 608, HPU010604, Pittsburgh, PA 15261.

Author Contributions: Conception and design: L.S. Zier, D.B. White.

Analysis and interpretation of the data: L.S. Zier, P.D. Sottile, S.Y. Hong, L.A. Weissfield, D.B. White.

Drafting of the article: L.S. Zier, L.A. Weissfield, D.B. White.

Critical revision of the article for important intellectual content: L.S. Zier, P.D. Sottile.

Final approval of the article: L.S. Zier, P.D. Sottile, D.B. White.

Provision of study materials or patients: L.S. Zier.

Statistical expertise: L.S. Zier, S.Y. Hong, L.A. Weissfield.

Obtaining of funding: L.S. Zier, D.B. White.

Administrative, technical, or logistic support: L.S. Zier.

Collection and assembly of data: L.S. Zier.

From the University of California, San Francisco, San Francisco, California, and the University of Pittsburgh, Pittsburgh, Pennsylvania.

Ann Intern Med. 2012;156(5):360-366. doi:10.7326/0003-4819-156-5-201203060-00008
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Background: Little is known about why surrogate decision makers for patients with advanced illness often have overly optimistic expectations about prognosis.

Objective: To determine how surrogates interpret prognostic statements and to explore factors influencing surrogates' interpretations of grim prognostic information.

Design: Multicenter, mixed-methods study.

Setting: Intensive care units of 3 hospitals in San Francisco, California.

Participants: 80 surrogates of critically ill patients.

Measurements: Participants recorded their interpretation of 16 prognostic statements using a standard probability scale. Generalized estimating equations were used to determine whether participants interpreted statements more optimistically as the expressed probability of survival decreased. Fifteen surrogates whose responses exhibited this trend participated in a semistructured interview.

Results: Participants' interpretations of prognostic statements expressing a low risk for death were relatively accurate, but interpretations of statements conveying a high risk for death were more optimistic than the actual meaning (P < 0.001; generalized estimating equation model). Interpretations of the statement “90% chance of surviving” did not differ from the actual meaning, but interpretations of “5% chance of surviving” were more optimistic and showed substantial variability (median, 90% [interquartile range, 90% to 95%; P = 0.11] vs. 15% [interquartile range, 5% to 40%; P < 0.001], respectively). Two main themes from the interviews explained this trend: surrogates' need to register optimism in the face of a poor prognosis and surrogates' belief that patient attributes unknown to the physician would lead to better-than-predicted outcomes.

Limitation: Surrogates' interpretations were elicited in an experimental setting rather than during actual clinician–surrogate conversations.

Conclusion: Inaccurate interpretations of physicians' prognostications by surrogates arise partly from optimistic biases rather than simply from misunderstandings.

Primary Funding Source: National Heart, Lung, and Blood Institute.


Grahic Jump Location

Figure 1. Surrogate decision makers' interpretations of physicians' prognostic statements.

Grahic Jump Location
Grahic Jump Location

Figure 2. Study flow diagram.

ICU = intensive care unit.

Grahic Jump Location




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