National questionnaire survey on what influences doctors' decisions about admission to intensive care
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7463.425 (Published 19 August 2004) Cite this as: BMJ 2004;329:425
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In planning this study, we had considered many more experimental
factors than we could test. We renounced testing patient sex because:
a) the main focus was on cancer versus non-cancerous disease as the
underlying health problem; for some of the most frequent cancers (breast,
prostate) the patient's sex is fixed.
b) the intensive care doctors among the coauthors (one woman, one man)
felt that different admission practices for men and women were very
unlikely. However, given the discrepancies we found between stated
admission criteria and the results of the vignette analysis, this issue
may need to be revisited, as suggested by Dr Dwyer.
Regarding the terms used in the paper and the identification of the
patients' sex, any ambiguity exists only in English. The vignettes were
written in French and German, and all used gendered terms: "patient"(M) or
"patiente"(F), "Patient"(M) or "Patientin"(F). This also means that the
study results are adjusted for the hypothetical patients' sex.
Competing interests:
Co-author of paper
Competing interests: No competing interests
Dr Harries provides a useful perspective on the psychological
mechanisms that may explain some of our results.
She notes that "a factor’s impact depends upon how much it varies
across cases." Meaning, I suppose, that real life variability (say, in
the proportions of cheerful and gloomy patients) may be less than the
50/50 used in the experimental design. That would be correct. However, we
did not ask respondents about the (quantitative) importance of a given
factor in the paptient population they see, but about the (qualitative)
importance of a given factor when deciding whether to admit or not a given
individual. So if doctors say in essence "no, we do not use the patient's
emotional state when deciding on an admission", but the vignette analysis
suggests they do (as a group), I do not think that factor variability can
explain this.
Dr Harries also warns against inferring too much from grouped
analyses to individual decisions. Agreed. The grouped analysis might point
to potential problems or issues that may require consideration by the
profession or by society at large, but will not necessarily help in
deciding about the best care for Mr A or Mrs X.
Competing interests:
Co-author of the paper
Competing interests: No competing interests
We welcome the publication of Escher and colleagues’ investigation
into the influences on doctors’ decisions about admission to intensive
care (1). Like clinical judgment analysis (2;3;4) this study explores both
explicitly stated ratings of the relative importance of factors and also
measures their tacit impact. The mismatch between these reiterates the
pattern that is regularly reported both for individual doctors’ (5;6;7)
and others’ (8) judgments and decisions. Whilst Escher and colleagues
suggest that “unconscious processes may be at work and lead to biased
decisions”, there are other explanations for this implicit-explicit
mismatch (9).
Firstly, a factor’s impact depends upon how much it varies
across cases. Participants rating relative importance prior to judging
sets of cases (as was the case in this study) don’t necessarily have
access to this information and have poorer ‘self-insight’ than those
rating relative importance afterwards (10). Similarly, participants whose
judgments are on representative sets of vignettes (rather than carefully
designed sets as here) also show better self-insight (8).
Secondly, there
are intra and inter- individual differences in how information is used.
Group analyses may not capture the information use of any individual, but
summarising across vignettes on which different cues have been used is
also likely to mislead: different heuristics may drive the decisions on
different cases (11) and relative importance of a factor may thus vary
from case to case (12). Whilst we congratulate the authors on interesting
results and a multi-method approach, conclusions that unconscious
processes are afoot, may be a little premature.
1. Escher M, Perneger TV, Chevrolet J-C. National questionnaire
survey on what influences doctors' decisions about admission to intensive
care. British Medical Journal 2004;329:425-30.
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HLF. Inability of rheumatologists to describe their true policies for
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knowing what you are doing. Acta Psychologica 2000;104:399-416.
Competing interests:
None declared
Competing interests: No competing interests
It is disappointing that this study did not include gender of the
patient as a factor of interest, given what is known about the impact of
gender in decision-making about other aspects of medical care. Worse,
given that patient gender is identified in 3 of the vignettes (either
explicitly by the description 'woman' or implicitly by type of cancer),
but obscured in others, one wonders how much the results are confounded by
gender as a kind of wild card in the otherwise structured approach to
allocation of variables. I wish I could say it was merely quaint that four
of the patients are identified as 'patients' (one implicitly male, the
other three undetermined) and two are identified as 'woman'. I wonder what
assumptions the respondents made?
Competing interests:
None declared
Competing interests: No competing interests
The fact that none medical factors influence decisions concerning
patients perception of disability, or doctors consideration of what is
appropriate treatment or referral, is well known. The current process of
certifying and justifying sickness absence by UK GPs is an example of a
particularly subjective process.
Competing interests:
None declared
Competing interests: No competing interests
ICU admission and non clinical factors
Dear Sir,
the decision to admit a patient to the intensive care unit (ICU) is only
one link in a chain of events [1], and nowadays we are inclined to think
that the decision process regarding admission to ICU is frequently not a
purely objective one based on medical suitability but is often influenced
by non clinical factors.
In the interesting article by Escher and co-workers [2] on the subject of
the factors influencing doctors’ decisions to admit a patient to ICU, the
authors consider a number of factors based on the literature and on their
own experience. The list of factors considered is certainly wide, but it
may be worth mentioning at least two further elements which have proved to
exert some considerable influence on the choices of ICU doctors.
The first is pressure in connection with economic factors: there are data
suggesting that income maximization may sometimes influence bed allocation
more than patient need [3]. The second element is pressure from
colleagues: a Europe-wide survey [4] found that 78% of ICU physicians
acknowleged that, although shortage of ICU beds is a common state of
affairs, they admitted patients with only a limited chance of survival
beyond a few days, and 64% admitted patients with no chance of survival.
This behaviour was attributed in part to pressure from the patients’
primary care physicians [5]. Recent Italian data also show that ICU
physicians consider their admission decisions may be influenced by
pressure “from above” and by pressure from the referring clinician [6].
I believe it is crucial to continue to gather all data possible relating
to ICU admission in order to obtain an overall “snapshot” of the
situation, to gain a more precise picture of circumstances which are
complex and variegated. This is an important starting point for improving
the decision-making processes and therefore the allocation of ICU
resources.
Refrences:
1.Levin PD, Sprung CL. The process of intensive care triage.
Intensive Care Med 2001;27:1441-1445
2.Escher M, Perneger TV, Chevrolet JC. National questionnaire survey
on what influences doctors’ decisions about admission to intensive care.
BMJ 2004;329:
3.Marshall MF, Schwenzer KJ, Orsina M et al. Influence of political
power, medical provincialism, and economic incentives on the rationing of
surgical intensive care unit beds. Crit Care Med 1992;20:387-394
4.Vincent JL. European attitudes towards ethical problems in
intensive care medicine: results of an ethical questionnaire. Intensive
Care Med 1990;16:256-264
5.Vincent JL. Ethical issues in critical care medicine: United States
and European views and differences. Intensive Care World 1996;13:142-144
6.Giannini A, Sgamma D, Izzo F, Moneta A. Physicians perceptions of
inappropriate admissions to intensive care units. Eur J Aneasthesiol
2004:21 (Suppl 32):A712
Competing interests:
None declared
Competing interests: No competing interests