Doctors’ Pessimism May Prevent ICU Admission

Key Point

Doctors may be overly pessimistic about survival rates for patients with COPD-related attacks, thus preventing patients who need help from entering the ICU.

Doctors may be overly pessimistic about the chances of survival for patients with attacks related to COPD, according to the November 1 online BMJ.

This pessimism may result in some patients being denied admission to the hospital for vital help, the investigators stated.

“Clinicians are generally pessimistic about the survival of patients with exacerbations of COPD and have particular problems in identifying those with poor prognosis,” Martin J. Wildman, PhD, of Northern General Hospital in Sheffield, United Kingdom, and colleagues stated. “Patients might therefore be inappropriately excluded from intensive care and the chance of intubation on the basis of a false prediction of futility.”

DISPARITY BETWEEN PROGNOSES AND OUTCOMES

The investigators studied results from 92 ICUs and three respiratory high dependency units in the UK that dealt with 832 patients 45 and older who had breathlessness, respiratory failure, or change in mental status due to a COPD attack, asthma, or both.

Information gathered during an 18-month period from a database covering 74% of UK ICUs said there was no significant difference in outcomes when comparing units that took part in the study and those that did not. Overall, 62% of patients survived 180 days after the incident, but clinicians’ prognoses were pessimistic, predicting a survival rate of just 49%. For the fifth of patients with the poorest prognosis according to the clinician, the predicted survival rate was 10% and the actual rate was 40%. The survival rates were 80% at discharge from ICU or high dependency units, 70% at discharge from the hospital, and 62% at 180 days after ICU admission.

ICU RESOURCE SHORTAGE TO BLAME?

In an accompanying editorial, Eddy Fan, MD, of the University of Toronto and Dale M. Needham, MD, PhD, of Johns Hopkins University in Baltimore, pointed to a scarcity of intensive care resources as a possible explanation for the study’s results. They stated that making decisions about admission to intensive care is complex, especially in the UK and southern Europe, where intensive care beds are often lacking. The editorialists also called for further studies to determine whether prognostic pessimism requires intervention aimed at doctors or at underlying health care systems that have inadequate provision of critical care services.

—Adriene Marshall

Suggested Reading
Afessa B, Morales IJ, Scanlon PD, Peters SG. Prognostic factors, clinical course, and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure. Crit Care Med. 2002;30(7):1610-1615.
Confalonieri M, Gorini M, Ambrosino N, et al. Respiratory intensive care units in Italy: a national census and prospective cohort study. Thorax. 2001;56(5):373-378.
Connolly MJ, Lowe D, Anstey K, et al. Admissions to hospital with exacerbations of chronic obstructive pulmonary disease: effect of age related factors and service organization. Thorax. 2006;61(10):843-848.
Fan E, Needham DM. Deciding who to admit to a critical care unit. BMJ. 2007 Nov 1; [Epub ahead of print].
Wildman MJ, Sanderson C, Groves J, et al. Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and Asthma Outcome Study (CAOS): multicentre observational cohort study. BMJ. 2007 Nov 1; [Epub ahead of print].

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