Psychological factors influence how patients interpret information

Here is the setup.  You’re working in the ICU.  You want to communicate a prognosis to the family of a patient who is so ill he cannot make decisions.  You sensitively state the facts: the patient has less than a 5% chance of survival.  Or perhaps you say “he will definitely not survive.”

The family confers, and decides that they want to focus on keeping him alive as long as possible.  You wonder to yourself, “I know what I said. What did they hear? Do they understand that he’s dying?”

A study from the Annals of Internal Medicine surveyed surrogates of seriously ill ICU patients.  Researchers presented surrogates with a range of possible prognostic statements for a hypothetical patient — not their loved one  – and asked them to mark what they interpreted the statement to mean on a scale from 0% to 100% chance of survival.  Results were astounding:

  • For optimistic statements, such as “He will definitely survive,” or, “He has a 90% chance of surviving,” almost all surrogates generally indicated agreement with the statement’s intent, interpreting the statements to mean >90% chance of survival.
  • For pessimistic statements, such as “He has a 5% chance of surviving,” or, “He will definitely not survive,” surrogates were much more optimistic, with mean interpretations in the 25-30% survival range, and some surrogates indicating 95% chance or greater likelihood of survival!
  • When these findings were shown back to surrogates, they were at a loss for how to explain their optimistic responses to the grim prognoses.

What to make of this?  The authors point out that there is much more to communicating accurate information than misunderstanding of numerical risks.  Psychological factors play a huge role in how patients hear and interpret information.

I remember my first day rotating on the palliative care service at the Brigham and Women’s Hospital.  Susan Block was holding forth about how dying patients and their surrogates, when confronted with a grim prognosis, sometimes simultaneously believe contradictory information: most of the time they hope for survival, but at some level, they recognize that they are dying.  The study seems to hint at such a complex psychological picture.  My guess is that forcing surrogates to assign a single number to such a complex psychological phenomena is where the study ran up against the limitations of its methods.

What to take away from this?  Telling a surrogate that the prognosis is grim is not the same thing as surrogates understanding that the prognosis is grim.  They may take away a substantially more optimistic message than intended.  This is important information to understand and teach.  The question is, what to do about it?

Here is where I disagree with the conclusion of the article: that these psychological biases are an obstacle to be overcome, or remedied, because “not all optimism is ethically benign.”  I worry that undermining the optimism at a vulnerable time could be harmful to the surrogates, and potentially detrimental to the relationship between ICU providers and surrogates.  Ultimately, this sort of approach may hinder rather than facilitate communication.

Rather, as Susan Block taught, our job is to prop up those psychological mechanisms that are supporting the surrogate, helping them to cope with a dreaded event, even as we’re preparing them in case things don’t go as they hope by providing realistic information.  Even if these goals seem at cross purposes.  A complex response to a complex psychological state.

Alex Smith is an Assistant Professor of Medicine, Department of Medicine, Division of Geriatrics at the University of California, San Francisco who blogs at GeriPal.

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  • Andrew Garland

    Life seems random, everyong has had close calls with injury or death, and most people think they will win the lottery at just the right time. Add in that they believe their prayers and attitude can support the ill person. The flip side is that accepting a bad outcome can help to kill that person.

    This classic scene in Dumb and Dumber shows how we believe in our chances for the best outcome. Jim Carey evaluates the news about his hopes for a relationship.
    Dumb and Dumber ‘There’s a Chance’

  • the Daily Medical Examiner

    Hope, indeed, springs eternal. When death seems imminent, we must learn how to re-channel that hope into attainable goals. Additionally, the path to understanding such a complex concept as the death of a loved one can’t be paved in a 15 minute session or in a statistical statement, i.e. 5% chance of survival. Most of us would hope for time to become acquainted with the nearing possibility of death before we are confronted with the immediate reality of dying.

  • Donna Blass

    With the cost of intensive care averaging or exceeding $10,000 per day these issues are more serious and urgent than this article implies. Historical practice has been to pull out all the stops with regard to intensive care at the request of the patient and/or family/surrogate. As this article aptly illustrates there has been a damn the torpedoes attitude with regard to disregarding costs, benefit, and potential outcome in deference to the wishes and whims of individuals who will not directly bear the financial costs of the tab for ICU and have no medical background with which to make an informed decision. Many health care professionals, let alone the general public, are unaware that the largest proportion of outlays by Medicare are for the cost of care during the last ten days of insureds lives. With every decade after the age of 65 the odds of a patient ever being discharged from an ICU alive — or with anything most people would consider a palatable life — fall off markedly. Every dollar spent on futile care in an ICU is a dollar that won’t be spent on helping some other individual prolong an all ready good state of health, or on primary prevention to obviate the need for intensive care in the first place.

  • Sue Wintz

    There’s more to the family response than meets the eye. As a board certified chaplain affiliated with HealthCare Chaplaincy in NY, I have over 30 years of experience working with families in ICU and trauma settings – and I’ve participated in hundreds of conversations with doctors and families. Sometimes the optimism is a cultural issue – the family’s culture may be one that doesn’t talk openly about death or has the belief that the words are uttered, they will happen. It may be a faith-based response – perhaps they are from a tradition that has taught them that to deny the power of a miracle indicates a lack of faith on their part. Beliefs and values are powerful and go much deeper than psychological factors alone.

    So what’s the answer? Obviously I would advocate for the presence of a board certified professional chaplain on the interdisciplinary team. By completing a spiritual assessment and building a relationship with a family the chaplain identifies the cultural, spiritual, and religious values that the family embraces and can communicate them to the physician and the rest of the team. By addressing them with the family – not to change them, but to work within them – communication is improved. Once that is done, then decisions can be made that are compatible with their beliefs and values as well as the best interest of the patient.

  • Virginia Seno

    When a patient is not likely to live, and when the physician has expressed this to family, that is the time to suggest hope for having the time they have left as they would want it to be. That exchanges for the hope they just lost (for more time) with hope that they can be with their person in a loving way while they die.

    Seems to me, that is what is missing in this scenario. People, as Dr. Block says, ‘know’ somewhere in themselves what is going on and what is best for the patient. It’s not that hard to get at that knowing, and it doesn’t necessarily take more time.

    If clinicians walk family through prognosis and choices for being in a peaceful way with their dying member, focusing on what they would want *given* that dying is imminent; the whole story changes for the better.

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