The findings, reported in the March 6 issue of the Annals of Internal Medicine, indicate that family members try to sustain hope and harbor beliefs that their loved one will defy medical odds.
Because family members often are called upon to act as surrogate decision-makers for patients too ill to communicate their own wishes, it is imperative that they have a reasonably accurate perception of the patient’s prognosis, said Douglas B. White, M.D., M.A.S., associate professor, Department of Critical Care Medicine.
“Research has shown us that prognostic information influences treatment decisions near the end of life,” he said. “But there’s evidence of disconnect between what the doctor says and how the surrogates interpret the meaning.”
For the study, the team surveyed 80 surrogate decision-makers at three ICUs in San Francisco. The participants read statements such as “He will definitely survive,” “He has a 90 percent chance of surviving,” “He has a 5 percent chance of surviving,” and “He will definitely not survive,” and then noted their interpretation of the survival odds on a scale marked in 10 percent intervals from 0 to 100 percent.
After completing the questionnaire, they were interviewed about their responses. The participants were assured that the statements were hypothetical and not related to their own loved one’s prognosis.
The researchers found that participants accurately interpreted statements when the prognosis was generally good. But that was not the case with poor prognoses: 40 percent of surrogates interpreted the 50 percent survival chance more optimistically than stated, and nearly two-thirds interpreted a 5 percent survival chance more optimistically than stated.
When asked to explain overly optimistic expectations, participant responses included “I hold on to hope strongly,” “There is still hope,” “We are talking about my father in this case, not just any patient,” and “They’re not giving you a real figure.”
“Our research indicates that in the ICU setting, family members want to see the glass as half full, even if it’s really nearly empty,” Dr. White noted. “They accurately interpreted statements conveying good prognoses, which means it’s not a simple misunderstanding of numbers that explains their misperceptions. Instead, they appear to be biased to optimism as a coping strategy to deal with the highly stressful situation of having a loved one near death.”
He noted that many participants didn’t realize they had been overly optimistic until it was pointed out. That disconnect might be very difficult to overcome in the real world of the ICU, where unrealistic optimism could lead to caregiver decisions that do not reflect the patient’s values.
Co-authors of the paper include Lucas S. Zier, M.D., and Peter D. Sottile, M.D., of the University of California, San Francisco; and Seo Yeon Hong and Lisa A. Weissfield, Ph.D., both of the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health.
The research was funded by grant R01HL094553 from the National Heart, Lung, and Blood Institute, part of the National Institutes of Health; the Greenwall Foundation; and the University of California Berkeley–University of California San Francisco Joint Medical Program.