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The Challenges of Prognosticating Persistent Critical Illness: A Qualitative Study.
Kaitland M Byrd1, Madeline M Lagina1, Kathleen T Lee1
1Division of Pulmonary and Critical Care Medicine (K. M. B., M. M. L., K. T. L., H. C. P., and E. M. V.), Department of Internal Medicine, University of Michigan; the HSR Center of Innovation (H. C. P. and E. M. V.), Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI; the Department of Internal Medicine (A. T.), University of Pittsburgh Medical Center, Pittsburgh, PA; the Division of Allergy, Pulmonary and Critical Care Medicine (J. M. K.), Department of Medicine, University of Wisconsin, Madison, WI; the Division of Pulmonary and Critical Care (T. J. I.), School of Medicine, and the Department of Health Policy and Management (T. J. I.), School of Public Health, John Hopkins University, Baltimore, MD.
Intensivists use patient factors and illness scripts for prognostication, but clinical setbacks and consultant input often alter these predictions. Understanding these factors is key for improving medical decision-making in the ICU.
Area of Science:
- Critical Care Medicine
- Medical Decision-Making
- Prognostication
Background:
- Intensivists face challenges in predicting critical events like new shock or acute hypoxic respiratory failure (AHRF) that lead to persistent critical illness (PerCI).
- Understanding how intensivists prognosticate for patients with PerCI is crucial for improving care.
Purpose of the Study:
- To explore the processes intensivists use to predict a patient's risk of new shock, AHRF, and PerCI.
- To identify the challenges intensivists encounter in prognostication within the ICU.
Main Methods:
- Semistructured interviews with 17 intensivists using chart-stimulated recall of patient cases.
- Qualitative content analysis of interviews focusing on information used for prognostication and encountered challenges.
Main Results:
- Intensivists contextualize patient factors at ICU admission and utilize illness scripts (disease mental models).
- Clinical setbacks and consultant input significantly impact prognostic estimates and predicted clinical trajectories.
- Prognostication is influenced by the intensivist's expertise and the nature of the patient's illness.
Conclusions:
- Intensivists' prognostication relies on initial patient data and established illness scripts.
- Dynamic factors like clinical setbacks and external advice frequently modify prognoses, influencing medical decisions.
- Further research into time-limited trials is recommended to manage prognostic uncertainty in critical care.
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