Chest
Volume 91, Issue 4, April 1987, Pages 515-521
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Clinical Investigations
Variability in Physician Estimates of Survival for Acute Respiratory Failure in Chronic Obstructive Pulmonary Disease

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Physician estimates of patient survival often influence clinical decisions. I studied physician estimates of survival for a patient with acute respiratory failure and underlying chronic obstructive pulmonary disease to identify the factors that may influence these estimates. Physicians (n = 205) completed the same patient management problem and estimated the length of survival for the hypothetical patient. Physician estimates of survival were quite variable, ranging from one month to five years. Shorter estimates of survival were associated with acquisition of select case information: 1) subjective information from family members and a professional colleague, and 2) physiologic and functional data previously demonstrated to be predictive of survival. The study suggests that estimates of survival for the same patient may vary among physicians because of different considerations of social and physiologic case information. Physician estimates of patient survival and treatment recommendations may become more uniform with additional education or decision aids regarding the prognostication of survival.

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METHODS

I presented a patient-management problem modeled after the ABIM certification examination questions to a group of physicians. They were requested to select a limited amount of available case information, indicate a treatment preference (intubation vs allowing to die), estimate the patient’s survival time if treated, and explain the rationale for their treatment decision.

Subjects were 205 internal medicine and family medicine physicians in King County (WA). They either were affiliated with the

RESULTS

Two hundred five physicians participated in the study, including 72 resident physicians and 55 attending physicians at the University of Washington, and 78 private practitioners. Seventy-two physicians were from the family medicine discipline (18 resident physicians, 14 attending physicians, and 40 private practitioners). One hundred thirty three physicians were from the internal medicine discipline (54 resident physicians, 41 attending physicians, and 38 private practitioners).

The estimates

DISCUSSION

Physician estimates of survival were investigated because they are influential factors in medical decisions that involve the elderly or individuals near the end of life, and are often based on limited empirical data. As such, this represents an area of uncertainty that may be affected by professional or social values rather than “scientific” considerations.

A patient management problem describing an elderly, debilitated patient with chronic obstructive pulmonary disease and acute respiratory

ACKNOWLEDGMENTS

The author wishes to thank Drs. Daniel Kent and Thomas Martin for their careful review of the manuscript.

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This project was supported in part by the Veterans Administration Northwest Health Services Research and Development Field Program and Geriatric Research Education and Clinical Center, and the Robert Wood Johnson Foundation.

Manuscript received August 20; revision accepted October 14.

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