Annie Lu1, Deepika Mohan2, Stewart C Alexander3, Craig Mescher4, Amber E Barnato5,6. 1. 1 Department of Pediatrics and Communicable Diseases, University of Michigan , Ann Arbor, Michigan. 2. 2 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania. 3. 3 Department of Consumer Science, Purdue University , West Lafayette, Indiana. 4. 4 Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota , Minneapolis, Minnesota. 5. 5 Section of Decision Sciences, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania. 6. 6 Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh , Pittsburgh, Pennsylvania.
Abstract
BACKGROUND: Framing is known to influence decision making. OBJECTIVE: The study objective was to describe language used by physicians when discussing treatment options with a critically and terminally ill elder. METHODS: High-fidelity simulation was used, involving an elder with end-stage cancer and life-threatening hypoxia, followed by a debriefing interview. Subjects were hospitalist, emergency medicine, and critical care physicians from three academic medical centers. Measures were observation of encounters in real time followed by content analysis of simulation and debriefing interview transcripts. During the simulation we identified the first mention ("broaching") of principal treatment options--intubation and mechanical ventilation (life-sustaining treatment [LST]) and palliation in anticipation of death (palliation)--and used constant comparative methods to identify language used. We identified physician opinions about the use of LST in this clinical context during the debriefing interviews, and compared language used with opinions. RESULTS: Among 114 physician subjects, 106 discussed LST, 86 discussed palliation, and 84 discussed both. We identified five frames: will (decided), must (necessary), should (convention), could (option), and ask (elicitation of preferences). Physicians broached LST differently than palliation (p<0.01), most commonly framing LST as necessary (53%), while framing palliation as optional (49%). Among physicians who framed LST as imperative (will or must), 16 (30%) felt intubation would be inappropriate in this clinical situation. CONCLUSIONS: In this high-fidelity simulation experiment involving a critically and terminally ill elder, the majority of physicians framed the available options in ways implying LST was the expected or preferred choice. Framing of treatment options could influence ultimate treatment decisions.
BACKGROUND: Framing is known to influence decision making. OBJECTIVE: The study objective was to describe language used by physicians when discussing treatment options with a critically and terminally ill elder. METHODS: High-fidelity simulation was used, involving an elder with end-stage cancer and life-threatening hypoxia, followed by a debriefing interview. Subjects were hospitalist, emergency medicine, and critical care physicians from three academic medical centers. Measures were observation of encounters in real time followed by content analysis of simulation and debriefing interview transcripts. During the simulation we identified the first mention ("broaching") of principal treatment options--intubation and mechanical ventilation (life-sustaining treatment [LST]) and palliation in anticipation of death (palliation)--and used constant comparative methods to identify language used. We identified physician opinions about the use of LST in this clinical context during the debriefing interviews, and compared language used with opinions. RESULTS: Among 114 physician subjects, 106 discussed LST, 86 discussed palliation, and 84 discussed both. We identified five frames: will (decided), must (necessary), should (convention), could (option), and ask (elicitation of preferences). Physicians broached LST differently than palliation (p<0.01), most commonly framing LST as necessary (53%), while framing palliation as optional (49%). Among physicians who framed LST as imperative (will or must), 16 (30%) felt intubation would be inappropriate in this clinical situation. CONCLUSIONS: In this high-fidelity simulation experiment involving a critically and terminally ill elder, the majority of physicians framed the available options in ways implying LST was the expected or preferred choice. Framing of treatment options could influence ultimate treatment decisions.
Authors: Judy E Davidson; Karen Powers; Kamyar M Hedayat; Mark Tieszen; Alexander A Kon; Eric Shepard; Vicki Spuhler; I David Todres; Mitchell Levy; Juliana Barr; Raj Ghandi; Gregory Hirsch; Deborah Armstrong Journal: Crit Care Med Date: 2007-02 Impact factor: 7.598
Authors: Katrina Armstrong; J Sanford Schwartz; Genevieve Fitzgerald; Mary Putt; Peter A Ubel Journal: Med Decis Making Date: 2002 Jan-Feb Impact factor: 2.583
Authors: Amber E Barnato; Heather E Hsu; Cindy L Bryce; Judith R Lave; Lillian L Emlet; Derek C Angus; Robert M Arnold Journal: Crit Care Med Date: 2008-12 Impact factor: 7.598
Authors: Raquel Herrero-Hahn; Rafael Montoya-Juárez; César Hueso-Montoro; Celia Martí-García; Diego Alejandro Salazar-Blandón; María Paz García-Caro Journal: Int J Environ Res Public Health Date: 2019-12-02 Impact factor: 3.390