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Original Research: CRITICAL CARE MEDICINE |

Surrogate Decision Makers' Responses to Physicians' Predictions of Medical Futility

Lucas S. Zier, MS; Jeffrey H. Burack, MD, MPP, BPhil; Guy Micco, MD; Anne K. Chipman, MS; James A. Frank, MD; Douglas B. White, MD, MAS
Author and Funding Information

From the University of California, Berkeley-University of California, San Francisco Joint Medical Program (Drs. Burack and Micco, Mr. Zier, and Ms. Chipman), and the Division of Community Health and Human Development (Drs. Burack and Micco), School of Public Health, University of California, Berkeley, CA; East Bay AIDS Research Institute (Dr. Burack), Alta Bates Summit Medical Center, Oakland, CA; The San Francisco Veterans Affairs Medical Center (Dr. Frank), San Francisco, CA; and the Division of Pulmonary and Critical Care Medicine (Drs. Frank and White), School of Medicine, and the Program in Medical Ethics (Dr. White), Department of Medicine, University of California, San Francisco, CA.

Correspondence to: Douglas B. White, MD, MAS, University of California, San Francisco, Program in Medical Ethics, 521 Parnassus Ave, Suite C-126, Box 0903, San Francisco, CA 94143-0903; e-mail: dwhite@medicine.ucsf.edu


This project was supported by a grant from the University of California, Berkeley-University of California, San Francisco Joint Medical Program (Mr. Zier), a grant from the University of California, San Francisco Dean's Office Medical Student Research Program (Mr. Zier), and a grant from the National Center for Research Resources [KL2 RR024130], a component of the National Institutes of Health and the National Institutes of Health Roadmap for Medical Research (Dr. White). Dr. White is also supported by a grant from the Greenwall Foundation Faculty Scholars Program.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(1):110-117. doi:10.1378/chest.08-2753
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Background:  Although physicians sometimes use the futility rationale to limit the use of life-sustaining treatments, little is known about how surrogate decision makers view this rationale. We sought to determine the attitudes of surrogates of patients who are critically ill toward whether physicians can predict futility and whether these attitudes predict surrogates' willingness to discontinue life support when faced with predictions of futility.

Methods:  This multicenter, mixed qualitative and quantitative study took place at three hospitals in California from 2006 to 2007. We conducted semistructured interviews with surrogate decision makers for 50 patients who were critically ill and incapacitated that addressed their beliefs about medical futility and inductively developed an organizing framework to describe these beliefs. We used a hypothetical scenario with a modified time–trade-off design to examine the relationship between a patient's prognosis and a surrogate's willingness to withdraw life support. We used a mixed-effects regression model to examine the association between surrogates' attitudes about futility and their willingness to limit life support in the face of a very poor prognosis. Validation methods included the use and integration of multiple data sources, multidisciplinary analysis, and member checking.

Results:  Sixty-four percent of surrogates (n = 32; 95% confidence interval [CI], 49 to 77%) expressed doubt about the accuracy of physicians' futility predictions, 32% of surrogates (n = 16; 95% CI, 20 to 47%) elected to continue life support with a < 1% survival estimate, and 18% of surrogates (n = 9; 95% CI, 9 to 31%) elected to continue treatment when the physician believed that the patient had no chance of survival. Surrogates with religious objections to the futility rationale (n = 18) were more likely to request continued life support (odds ratio, 4; 95% CI, 1.2 to 14.0; p = 0.03) than those with secular or experiential objections (n = 15; odds ratio, 0.95; 95% CI, 0.3 to 3.4; p = 0.90).

Conclusions:  Doubt about physicians' ability to predict medical futility is common among surrogate decision makers. The nature of the doubt may have implications for responding to conflicts about futility in clinical practice.

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