"It's not just what the doctor tells me:" factors that influence surrogate decision-makers' perceptions of prognosis.

The majority of critically ill patients in intensive care units (ICUs) depend on surrogate decision-makers to make end-of-life decisions on their behalf (1, 2). To make informed choices, surrogates must have a clear understanding of the patient’s diagnosis and likely prognosis. Despite the difficulty of these decisions and the ambivalence that many surrogate decision-makers report (3), most surrogates wish to participate actively in treatment decisions (4), view communication with physicians as one of the most important aspects of critical care (5–7), and desire timely, honest discussions about prognosis with their loved one’s physician (2). The complexities of physicians’ prognostication have been well-described, most extensively by Christakis (8). Previous research suggests that physicians typically base their prognostic estimates on previous experience caring for patients with similar disease, population-based survival estimates, and the physiologic status of the patient (9–11). Other research has identified social interactional factors and physician attributes that may affect physicians’ prognostications (8, 12). Physicians view the task of prognostication as one of the most difficult aspects of medicine (8). Although a number of studies have documented that surrogates’ estimates of prognosis are often at odds with the physician’s prognostic estimates (13, 14), comparatively little is known about how surrogates arrive at an understanding of the patient’s prognosis. Most commentators have postulated that poor communication is the cause of physician–surrogate discordance over prognosis (8, 15, 16). Our clinical experience has been that even with excellent communication, there sometimes remains a gap between the physician and surrogate about a patient’s prognosis. This raises the possibility that physicians and surrogates may systematically differ in how they formulate prognostic estimates. It is crucial to understand this element of surrogate decision-making if we are to move forward in improving decision-making for critically ill patients. Therefore, we conducted semistructured interviews with surrogates of critically ill patients to determine how they arrive at their assessment of a patient’s prognosis.