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. 2004 Jun;30(3):304–307. doi: 10.1136/jme.2002.001537

Certainty and mortality prediction in critically ill children

J Marcin 1, R Pretzlaff 1, M Pollack 1, K Patel 1, U Ruttimann 1
PMCID: PMC1733866  PMID: 15173368

Abstract

Objectives: The objective of this study is to investigate the relationship between a physician's subjective mortality prediction and the level of confidence with which that mortality prediction is made.

Design and participants: The study is a prospective cohort of patients less than 18 years of age admitted to a tertiary Paediatric Intensive Care Unit (ICU) at a University Children's Hospital with a minimum length of ICU stay of 10 h. Paediatric ICU attending physicians and fellows provided mortality risk predictions and the level of confidence associated with these predictions on consecutive patients at the time of multidisciplinary rounds within 24 hours of admission to the paediatric ICU. Median confidence levels were compared across different ranges of mortality risk predictions.

Results: Data were collected on 642 of 713 eligible patients (36 deaths, 5.6%). Mortality predictions greater than 5% and less than 95% were made with significantly less confidence than those predictions <5% and >95%. Experience was associated with greater confidence in prognostication.

Conclusions: We conclude that a physician's subjective mortality prediction may be dependent on the level of confidence in the prognosis; that is, a physician less confident in his or her prognosis is more likely to state an intermediate survival prediction. Measuring the level of confidence associated with mortality risk predictions (or any prognostic assessment) may therefore be important because different levels of confidence may translate into differences in a physician's therapeutic plans and their assessment of the patient's future.

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Selected References

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  1. Christakis N. A., Iwashyna T. J. Attitude and self-reported practice regarding prognostication in a national sample of internists. Arch Intern Med. 1998 Nov 23;158(21):2389–2395. doi: 10.1001/archinte.158.21.2389. [DOI] [PubMed] [Google Scholar]
  2. Christakis N. A., Lamont E. B. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ. 2000 Feb 19;320(7233):469–472. doi: 10.1136/bmj.320.7233.469. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Christakis N. A. The ellipsis of prognosis in modern medical thought. Soc Sci Med. 1997 Feb;44(3):301–315. doi: 10.1016/s0277-9536(96)00100-1. [DOI] [PubMed] [Google Scholar]
  4. Christakis Nicholas A. Prognostication and bioethics. Daedalus. 1999 Fall;128(4):197–214. [PubMed] [Google Scholar]
  5. Christensen C., Cottrell J. J., Murakami J., Mackesy M. E., Fetzer A. S., Elstein A. S. Forecasting survival in the medical intensive care unit: a comparison of clinical prognoses with formal estimates. Methods Inf Med. 1993 Aug;32(4):302–308. [PubMed] [Google Scholar]
  6. Knaus W. A., Wagner D. P., Draper E. A., Zimmerman J. E., Bergner M., Bastos P. G., Sirio C. A., Murphy D. J., Lotring T., Damiano A. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest. 1991 Dec;100(6):1619–1636. doi: 10.1378/chest.100.6.1619. [DOI] [PubMed] [Google Scholar]
  7. Kruse J. A., Thill-Baharozian M. C., Carlson R. W. Comparison of clinical assessment with APACHE II for predicting mortality risk in patients admitted to a medical intensive care unit. JAMA. 1988 Sep 23;260(12):1739–1742. [PubMed] [Google Scholar]
  8. Lynn J., Harrell F., Jr, Cohn F., Wagner D., Connors A. F., Jr Prognoses of seriously ill hospitalized patients on the days before death: implications for patient care and public policy. New Horiz. 1997 Feb;5(1):56–61. [PubMed] [Google Scholar]
  9. Marcin J. P., Pollack M. M., Patel K. M., Ruttimann U. E. Combining physician's subjective and physiology-based objective mortality risk predictions. Crit Care Med. 2000 Aug;28(8):2984–2990. doi: 10.1097/00003246-200008000-00050. [DOI] [PubMed] [Google Scholar]
  10. Marcin J. P., Pollack M. M., Patel K. M., Sprague B. M., Ruttimann U. E. Prognostication and certainty in the pediatric intensive care unit. Pediatrics. 1999 Oct;104(4 Pt 1):868–873. doi: 10.1542/peds.104.4.868. [DOI] [PubMed] [Google Scholar]
  11. McClish D. K., Powell S. H. How well can physicians estimate mortality in a medical intensive care unit? Med Decis Making. 1989 Apr-Jun;9(2):125–132. doi: 10.1177/0272989X8900900207. [DOI] [PubMed] [Google Scholar]
  12. Perkins H. S., Jonsen A. R., Epstein W. V. Providers as predictors: using outcome predictions in intensive care. Crit Care Med. 1986 Feb;14(2):105–110. [PubMed] [Google Scholar]
  13. Pollack M. M., Patel K. M., Ruttimann U. E. PRISM III: an updated Pediatric Risk of Mortality score. Crit Care Med. 1996 May;24(5):743–752. doi: 10.1097/00003246-199605000-00004. [DOI] [PubMed] [Google Scholar]
  14. Poses R. M., Bekes C., Copare F. J., Scott W. E. The answer to "What are my chances, doctor?" depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients. Crit Care Med. 1989 Aug;17(8):827–833. doi: 10.1097/00003246-198908000-00021. [DOI] [PubMed] [Google Scholar]
  15. Poses R. M., Bekes C., Winkler R. L., Scott W. E., Copare F. J. Are two (inexperienced) heads better than one (experienced) head? Averaging house officers' prognostic judgments for critically ill patients. Arch Intern Med. 1990 Sep;150(9):1874–1878. [PubMed] [Google Scholar]
  16. Poses R. M., McClish D. K., Bekes C., Scott W. E., Morley J. N. Ego bias, reverse ego bias, and physicians' prognostic. Crit Care Med. 1991 Dec;19(12):1533–1539. doi: 10.1097/00003246-199112000-00016. [DOI] [PubMed] [Google Scholar]
  17. Rich B. A. Defining and delineating a duty to prognosticate. Theor Med Bioeth. 2001 Jun;22(3):177–192. doi: 10.1023/a:1011466711211. [DOI] [PubMed] [Google Scholar]
  18. Sharp M. C., Strauss R. P., Lorch S. C. Communicating medical bad news: parents' experiences and preferences. J Pediatr. 1992 Oct;121(4):539–546. doi: 10.1016/s0022-3476(05)81141-2. [DOI] [PubMed] [Google Scholar]
  19. Stevens S. M., Richardson D. K., Gray J. E., Goldmann D. A., McCormick M. C. Estimating neonatal mortality risk: an analysis of clinicians' judgments. Pediatrics. 1994 Jun;93(6 Pt 1):945–950. [PubMed] [Google Scholar]

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