Table 2:

How Physician Interests Compete with ICU Patient Interests

Secondary interest	How a patient’s care could be affected
Work quotas	Intensivist salaries may require billing patients for a minimum number of relative value units (RVUs) creating an incentive to perform tests and procedures.
Legal risk	Diagnostic tests or imaging may be ordered out of concern about malpractice litigation. After an error, fear of a wrongful death suit may drive life-prolonging treatment.
Study recruitment or outcome	Intensivists who are also clinical investigators have an interest in enrolling eligible patients in studies to meet recruitment targets and in study results. Example: If a patient is enrolled in a study with a primary outcome of extubation failure, intensivists may attempt to delay re-intubation with additional breathing treatments or non-invasive ventilation, but while a similar patient not enrolled in the study is reintubated earlier.
Conflict avoidance	Patients and their family experience high emotional distress, often expressed as sadness or anger when a poor prognosis is disclosed. Disclosure of prognosis is delayed to avoid witnessing and responding to this reaction.
Maintaining team relations	Treatment decisions prioritize work flow rather than patient welfare. Example: A Foley catheter remain in place for a patient to increase ease of nursing care.
Avoiding bureaucracy	Intensivists may be less likely to prescribe therapies requiring an approval process. Example: An intensivists waits until 22:01 to place an order for an antibiotic to avoid the additional forms and phone calls required for antibiotic approval when antibiotic stewards are on-duty.
Curiosity	Desire to understand the pathophysiology of disease may influence diagnostic testing or imaging decisions even if results aren’t expected to impact patient care.
Fame	Unusual treatments are more likely to garner positive media attention than the standard of care.
Religious belief	Intensivists who adhere to a religious tradition that condemns withdrawing life support may avoid discussing this option with patients or family members who are requesting evaluation of the goals of care.
Financial gain	Intensivists may preferentially prescribe or utilize products from companies they have invested in or that provide financial support through grants or honoraria.