May 22, 2008 An important study raises concern about the way intensive care physicians approach patients and families facing serious end-of-life medical decisions. Based on interviews with more than 1,200 ICU physicians at five major medical centers across the country, researchers conclude that physicians are less comfortable discussing end-of-life issues and do it less frequently with African-American patients and their families than with Caucasian patients and families.
J. Daryl Thornton, M.D., M.P.H., of the Center for Reducing Health Disparities at MetroHealth Medical Center in Cleveland and Case Western Reserve University (CWRU), an assistant professor at CWRU, will present the findings at the American Thoracic Society's 2008 International Conference in Toronto on Wednesday, May 21.
One in five Americans will die in the ICU or shortly after a stay there, and, frequently, their deaths follow a decision made by families to withdraw life-sustaining therapies. "That is why it is so important that physicians are comfortable delivering difficult and sometimes complex diagnoses, potential outcomes and prognoses to patients and families in the ICU," said Dr. Thornton. "Our study suggests there may be some underlying biases and/or discomfort among physicians, which impacts their ability to have these difficult conversations with families."
"We had previously shown that ICU physicians, when predicting likelihood of survival of their patients, are less likely to predict that their African-Americans patients will survive," he continued. "Ironically, those African-Americans were more likely to survive. These two studies, taken together, suggest we need to collect more information about what impacts the prognostic decisions by physicians, and whether any underlying biases are influencing the way they communicate with patients and families."
The researchers examined data from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), which was conducted between 1989 and 1994 involving a group of 9,105 seriously ill hospitalized patients and their 1,241 physicians at five major medical centers across the country. On the third day of the study, physicians were asked if they had had prognostic conversations with their patients or their patients' surrogates (the person appointed by the patient to make their medical decisions).
Patients or their surrogates were also interviewed at the same time to assess their functional level two weeks prior to being admitted to the hospital, income, race, age and insurance status.
After adjusting for a variety of potentially confounding factors, such as severity of illness and insurance status, physicians reported having had prognostic conversations with 58 percent of their white patients, but only 41 percent of their African-American patients. Furthermore, physicians were less than half (43 percent) as likely to report feeling comfortable during those conversations with their African-American patients. This was true regardless of the actual prognosis.
"We acknowledge that this study uses data that is dated. The findings should be replicated and would be an important area for health disparities research--understanding the effects of physician biases on decision-making, communication and patient outcomes in the ICU," said Dr. Thornton. "By having a detailed understanding of the components of this intricate relationship, interventions can be implemented to enable the provision of more culturally sensitive and equitable care in the ICU."
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