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Families may be too optimistic about dim prognosis

By Amy Norton

NEW YORK (Reuters Health) - When families get the tough news that a critically ill loved one is unlikely to survive, they may often believe the odds are better than the doctor is predicting, a small study suggests.

Research has shown that families tend to have overly optimistic expectations of survival when a loved one is critically injured or ill. And experts have suspected that it may be because of miscommunication.

"People have tended to ascribe it to either doctors not discussing (prognosis), or families not understanding what the doctor is telling them," said Dr. Douglas B. White, the senior researcher on the new study.

If that were the case, the remedy would be relatively simple -- doctors could be clearer, said White, an associate professor of critical care medicine at the University of Pittsburgh Medical Center.

But in recent research, White and his colleagues have found that the issue seems more complicated. And this latest study, reported in the Annals of Internal Medicine, supports that.

White's team asked 80 family members of critically ill patients in the intensive care unit (ICU) to interpret a set of hypothetical "prognostic statements" -- statements not related to their actual family member.

Overall, the researchers found, people interpreted a good prognosis correctly: That is, if the statement were, "He has a 90 percent chance of surviving," study participants interpreted the prognosis as meaning just that.

But if the outlook was more grim, families tended to give the prognosis a more positive spin.

When the hypothetical patient had a 50 percent chance of surviving, four in 10 study participants had a more optimistic outlook -- typically seeing it as anywhere from a 50 to 70 percent chance.

And when the odds of survival were just 5 percent, two-thirds of participants had a more positive interpretation.

"If families can understand a 90 percent chance of survival, they should also be able to understand a five percent chance," White said. That, he added, indicates that families are not simply misunderstanding what doctors are saying.

So why the discrepancy?

In interviews with 15 study participants, the researchers got some clues.

One issue was basically trust. "There's some skepticism about doctors' ability to predict the future," White said.

Families also tended to believe that even if doctors can predict the average likelihood of survival, any one patient can still beat the odds. "They may think, 'OK, you can predict the average, but you don't know my mom. She'll do better than the average because she's strong,'" White said.

Of course, doctors cannot perfectly predict the future, and some people do beat the odds.

But the concern, according to White, is that if families systematically have overly optimistic attitudes, they might not make decisions that are in line with what their critically ill loved one would want.

If a patient's heart stops pumping blood through the body, for instance, doctors can try to restore a normal heart rhythm with CPR. Or if they can no longer breathe on their own, they can be placed on a mechanical ventilator. But for someone who is seriously ill -- with advanced cancer, for instance -- those measures could prolong, but not save, their lives.

This study did not look at how attitudes about prognosis affected family members' decisions.

But past studies have suggested that people's interpretations of prognosis do affect end-of-life decisions, White noted.

There's evidence, he said, that when people understand the reality of what CPR can do, for instance, they're less likely to want it. (CPR is most likely to be effective if an otherwise healthy person has a heart attack, for example. When someone is critically ill, even if CPR gets the heart started again, it is very unlikely that they'll recover enough to leave the hospital.)

There are some potential ways to give families a more realistic outlook, according to White.

Often, he said, families need time. So instead of a one-time discussion, doctors can give families time to process what they've been told, then talk with them again about the prognosis.

"There should be a series of discussions where families can ask questions and express their emotions," White said.

It might also help, he said, if doctors explain the basis for their prognosis -- that it's not just a number pulled from the air.

But at the same time, White added, "we have to acknowledge that there are limits to how precise and certain physicians can be in predicting the future."

SOURCE: http://bit.ly/xjd4Qw Annals of Internal Medicine, March 6, 2012.

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