Thanh H Neville1, Joshua F Wiley, Eric S Holmboe, Chi-Hong Tseng, Paul Vespa, Eric C Kleerup, Neil S Wenger. 1. Dr. Neville is assistant professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. Mr. Wiley is a doctoral student in health and quantitative psychology, University of California, Los Angeles, Los Angeles, California. Dr. Holmboe is senior vice president, Milestones Development and Evaluation, Accreditation Council for Graduate Medical Education, and professor adjunct of medicine, Yale University School of Medicine, New Haven, Connecticut. Dr. Tseng is associate professor, Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. Dr. Vespa is professor of neurology and neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. Dr. Kleerup is clinical professor, Department of Medicine, Division of Pulmonary and Critical Care, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. Dr. Wenger is professor, Department of Medicine, Division of General Internal Medicine and Health Services Research, and director, Health System Ethics Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, and a scientist at RAND Health, Santa Monica, California.
Abstract
PURPOSE: Knowing when patients are too ill to benefit from intensive care is essential for clinicians to recommend aggressive or palliative care as appropriate. To explore prognostic ability among critical care fellows, the authors compared fellows' and attendings' assessments of futile critical care and evaluated factors associated with assessments. METHOD: Thirty-six attendings and 14 fellows in intensive care units at the University of California, Los Angeles, were surveyed daily for three months (December 2011-March 2012) to identify patients perceived as receiving futile treatment. Frequency of futile treatment assessments and reasons listed by attendings versus fellows were compared. Predictors of futile treatment assessments by provider type were assessed using multivariate probit models. RESULTS: Attendings made 6,897 assessments on 1,125 patients; fellows made 4,407 assessments on 773 patients. Fellows assessed 161 (20.8%) patients as receiving futile treatment, compared with attendings (123 [10.9%] patients, P<.001), and listed fewer reasons that treatment was futile (P<.001). Fellows were more likely to assess a patient as receiving futile treatment by the second day, whereas attendings took four days. Patients assessed as receiving futile treatment by fellows were less likely than patients so assessed by attendings to die in the hospital (51% versus 68%, P=.003) and within six months (62% versus 85%, P<.001). CONCLUSIONS: Fellows made earlier assessments and judged more patients to be receiving futile treatment than attendings, and their assessments were less predictive of mortality, suggesting that assessment of treatment appropriateness develops with experience.
PURPOSE: Knowing when patients are too ill to benefit from intensive care is essential for clinicians to recommend aggressive or palliative care as appropriate. To explore prognostic ability among critical care fellows, the authors compared fellows' and attendings' assessments of futile critical care and evaluated factors associated with assessments. METHOD: Thirty-six attendings and 14 fellows in intensive care units at the University of California, Los Angeles, were surveyed daily for three months (December 2011-March 2012) to identify patients perceived as receiving futile treatment. Frequency of futile treatment assessments and reasons listed by attendings versus fellows were compared. Predictors of futile treatment assessments by provider type were assessed using multivariate probit models. RESULTS: Attendings made 6,897 assessments on 1,125 patients; fellows made 4,407 assessments on 773 patients. Fellows assessed 161 (20.8%) patients as receiving futile treatment, compared with attendings (123 [10.9%] patients, P<.001), and listed fewer reasons that treatment was futile (P<.001). Fellows were more likely to assess a patient as receiving futile treatment by the second day, whereas attendings took four days. Patients assessed as receiving futile treatment by fellows were less likely than patients so assessed by attendings to die in the hospital (51% versus 68%, P=.003) and within six months (62% versus 85%, P<.001). CONCLUSIONS: Fellows made earlier assessments and judged more patients to be receiving futile treatment than attendings, and their assessments were less predictive of mortality, suggesting that assessment of treatment appropriateness develops with experience.
Authors: Charles P Friedman; Guido G Gatti; Timothy M Franz; Gwendolyn C Murphy; Fredric M Wolf; Paul S Heckerling; Paul L Fine; Thomas M Miller; Arthur S Elstein Journal: J Gen Intern Med Date: 2005-04 Impact factor: 5.128
Authors: Elizabeth C Bernabeo; Matthew C Holtman; Shiphra Ginsburg; Julie R Rosenbaum; Eric S Holmboe Journal: Acad Med Date: 2011-05 Impact factor: 6.893
Authors: Thanh N Huynh; Eric C Kleerup; Joshua F Wiley; Terrance D Savitsky; Diana Guse; Bryan J Garber; Neil S Wenger Journal: JAMA Intern Med Date: 2013-11-11 Impact factor: 21.873
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