Medical futility: Predicting outcome of intensive care unit patients by nurses and doctors - A prospective comparative study

Objective. First, to assess the pattern of the prediction of intensive care unit patients' outcome with regard to survival and quality of life by nurses and doctors and, second, to compare these predictons with the quality of life reported by the surviving patients. Design. Prospective opinion survey of critical care providers; comparison with follow-up for survival, functional status, and quality of life. Setting: Six-bed medical intensive care unit subunit of a 1,000-bed tertiary care, university hospital. Patients: All patients older than 18 yrs, admitted to the medical intensive care unit for > 24 hrs over a 1-yr period (December 1997 to November 1998). Interventions: Daily judgment of eventual futility of medical interventions by nurses and doctors with respect to survival and future quality of life. Telephone interviews with discharged patients for quality of life and functional status 6 months after intensive care unit admission. Measurements and Main Results: Data regarding 521 patients including 1,932 daily judgments by nurses and doctors were analyzed. Disagreement on at least one of the daily judgments by nurses and doctors was found in 21% of all patients and in 63% of the dying patients. The disagreements more frequently concerned quality of life than survival. The higher the Simplified Acute Physiology Score and the longer the intensive care unit stay, the more divergent judgments were observed (p < .001). In surviving and dying patients, nurses gave more pessimistic judgment and considered withdrawal more often than did doctors (p < .001). Patients only rarely indicated bad quality of life (6%) and severe physical disability (2%) 6 months after intensive care unit admission. Compared with patients' own assessment, neither nurses nor doctors correctly predicted quality of life; false pessimistic and false optimistic appreciation was given. Conclusions. Disagreement between nurses and doctors was frequent with respect to their judgment of futility of medical interventions. Disagreements most often concerned the most severely ill patients. Nurses, being more pessimistic in general, were more often correct than doctors in the judgment of dying patients but proposed treatment withdrawal in some very sick patients who survived. Future quality of life cannot reliably be predicted either by doctors or by nurses.