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September 1, 2010

A paper in the June 2010 Journal of Trauma looks at the accuracy of survival and non-survival predictions on critically ill trauma patients by healthcare providers, with 326 predictions made on 223 patients.  They also looked at the accuracy of various statistical scoring tools (SOFA, APACHE II, RTS, ISS, TRISS).  Overall, health care providers were better outcome predictors than were the scoring systems.  However, nothing provided 100% accuracy.  In fact, of patients that attending physicians predicted would die, 38% actually lived and 5% went home directly without going to a skilled nursing facility or a rehabilitation unit.

For years, I’ve been explaining the possible worst-case scenario to families of severely ill or injured patients.  In our out-of-control, suit-happy society, we no longer give them reassurance that “everything will be all right,” because anything other than a perfect outcome could be grounds for a lawsuit.  By “hanging crepe,” families are prepared for the worst.  They can understand the odds stacked against our efforts to pull their loved one through their brush with death.  In fact, if the patient survives, we look like heroes.

Yet now it seems that I’m seeing a greater number of families throw in the towel long before we’ve given up hope.  Recently, a spouse chose to discontinue life support on a head-injured motorcyclist who’d improved from a GCS of 3T (worst) to 7T (halfway to normal) and was close to extubation.   She made her decision because she feared a chronic vegetative existence for her husband.  I suspect our bleak presentations and television dramas influence them, and that’s unfortunate.  After all, as the study shows, we can’t predict.  After all these years and all our developments, we still can’t tell you what’s going to happen, whether they’ll live or die.  We don’t have a crystal ball.

Our best plan is to proceed with aggression as long as we’re seeing improvements in the patient’s condition.  We should only concede futility when nothing seems to be working.

The paradigm shift in medicine is for families to understand that plan.

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