Article Text

Download PDFPDF
Sources of variability in uncertain medical decisions in the ICU: a process tracing study
  1. O Kostopoulou1,
  2. M Wildman2
  1. 1Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT, UK
  2. 2Specialist Registrar in Respiratory Medicine, Critical Care Unit, City Hospital, Birmingham B18 7QH, UK
  1. Correspondence to:
 Dr O Kostopoulou
 Research Fellow, Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT, UK;


Background: Consistency of medical decision making (equity) is an important component of quality of care. When patients with chronic obstructive pulmonary disease (COPD) present with an exacerbation needing respiratory support they may die if it is not provided. However, if the disease has reached its terminal stage, ventilation will prolong the process of dying. The ventilation outcome is uncertain and there is evidence of variability when this decision is made, the sources of which are not well understood.

Objectives: To identify sources of variability and propose ways of tackling them in order to promote equity in this type of medical decision.

Methods: Six case histories were selected from hospital records of COPD patients. Fourteen senior doctors from seven hospitals in the West Midlands participated. A process tracing approach was used which consisted of (1) withholding case information until specifically requested by the doctors, (2) estimating survival during the decision making process, and (3) concurrent questioning regarding information interpretation and its impact on survival estimates and decisions.

Results: The observed decision variability was attributed to doctors attaching importance to different information, gathering different information, and interpreting information differently. There were significant differences between doctors in the amount of information requested.

Conclusions: Differences in information gathering and interpretation by clinicians can result in different decisions being made about the same patient. This variation may exist for other uncertain medical decisions and may be tackled by providing clinicians with prognostic models in the form of usable decision aids.

  • decision making
  • process tracing
  • intensive care
  • chronic obstructive pulmonary disease

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • OK and MW conceived and designed the study. OK conducted the process tracing with the clinicians, analysed the results, and wrote the paper. MW obtained ethical approval, checked and standardised the cases, advised on medical issues, and commented on the paper. OK is the guarantor for the study.

  • OK is funded by a DoH R&D/PPP National Primary Care Postdoctoral Award.

Linked Articles

  • Quality lines
    BMJ Publishing Group Ltd