Differences Between Attendings’ and Fellows’ Perceptions of Futile Treatment in the Intensive Care Unit at One Academic Health Center: Implications for Training

Care for the critically ill is complex, dynamic, and resource-intensive; decisions must be made daily whether to initiate, continue, or withhold/withdraw life-sustaining treatments. Accurate prognostication and identification of patients who might benefit or will not benefit from aggressive treatment are essential aspects of patient care in the intensive care unit (ICU). Such clinical understanding is essential for the communication that leads to critical care decision making, which translates into family satisfaction1 and to transitions toward palliative care when patients will no longer benefit from critical care. Scoring systems have been developed to objectively predict outcomes among seriously ill patients, however, several studies suggest that clinicians are able to as accurately prognosticate mortality for individual patients by a gestalt process compared to prognostic scoring systems.2-4 Poses and colleagues showed that critical care clinicians have excellent overall discriminating ability concerning survival (separating patients into those who survive and those who die) and that attending physicians’ predictions were better calibrated (how well predicted probabilities agreed with actual observed risk) than those of house-officers.5 Elsewhere, Poses and colleagues point out that accurate prognostic calibration can be an important determinant of quality of care.6 The critical care physician must be able to predict not only a patient’s survival probability, but also whether intensive care unit interventions can influence this probability. Fellows in critical care have completed at least 3 years of post-graduate training, usually in internal medicine, and are responsible for supervising residents in the ICU of academic medical centers while they learn the skills of critical care. Fellows learn procedures and the approach to the critically ill patient. During training fellows likely also develop their prognostic ability. To explore prognostic capability among critical care fellows, we compared fellows’ and attendings’ assessments of futile or probably futile critical care and evaluated factors associated with these assessments. This report builds on our previous work in which attending physicians’ assessments of futile treatment were quantified,7 and explores whether and how assessments from critical care physicians-in-training differ from attendings. We hypothesized that fellows would not discern whether aggressive critical care is futile as accurately as attending physicians.