Familial optimism fuels invasive care at end of life

The expectations of surrogate decision-makers — typically family members — for critically ill patients regarding prognosis are often in contrast with those of the critical care physician, according to findings recently published in JAMA.

While prognostic misperceptions among a patient's family members are common, little research has been conducted to determine why these misperceptions persist. Better knowledge regarding the general optimism held by surrogate decision-makers could help intensivists communicate more effectively with family members regarding end-of-life care.

To provide more clarity surrounding this optimism, Douglas B. White, MD, professor at the University of Pittsburgh School of Medicine's Department of Critical Care Medicine, and colleagues surveyed 99 physicians and 229 surrogate decision-makers. Both groups were asked to estimate a patient's chance of survival from zero to 100. In more than half of cases, there was a significant difference in expectations between surrogates and physicians. A significant difference was defined as discordance of at least 20 percent on the survey scale.

When interviewing surrogates about these disparities in expectation, researchers found that there was an element of medical misunderstanding involved in the majority of cases. Still, even in cases in which family members were medically well-informed, differences in expectations persisted more than 50 percent of the time. The driving factors behind this optimism were hope, strength and faith.

"The first and most common reason is that these family members believe that by holding a more optimistic belief about prognosis, that will actually help the patient have a better outcome," Dr. White told CBS News. "This notion that hope will actually influence the patient's outcome arose in half the cases."

Surrogates also reported that physicians likely underestimated the strength of the patient. "The families would say 'yeah, the doctor knows what happens to most people, but he doesn't know my mom and my mom is going to do better than the average patient,'" said Dr. White.

Religion, or a hope or belief in divine intervention also bolstered familial optimism among study participants.

The results highlight the importance of effective communication between the physician and a patient's family members regarding end of life care. Optimism, in regards to treatment choices, can often do more harm than good.

Dr. White told CBS News, "The concern is that patients would get a lot more intensive, invasive treatments than they would choose for themselves...this is the kind of end-of-life care that can be harmful to patients in terms of dignity and respect. It's also extremely costly the healthcare system."

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