Power and limitations of daily prognostications of death in the medical intensive care unit

• Published in: Critical care medicine Vol. 39; no. 3; pp. 474 - 479
• Main Authors: Meadow, William, Pohlman, Anne, Frain, Laura, Ren, Yaya, Kress, John Paul, Teuteberg, Winnie, Hall, Jesse
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD by the Society of Critical Care Medicine and Lippincott Williams & Wilkins 01-03-2011; Lippincott Williams & Wilkins
• Subjects: Age Factors; Aged; Analysis of Variance; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Clinical death. Palliative care. Organ gift and preservation; Female; Hospital Mortality; Humans; Intensive care medicine; Intensive Care Units - statistics & numerical data; Internship and Residency; Length of Stay; Linear Models; Male; Medical sciences; Medical Staff, Hospital; Middle Aged; Nursing Staff, Hospital; Patient Discharge - statistics & numerical data; Prognosis; ROC Curve; Sensitivity and Specificity; Withholding Treatment - statistics & numerical data; clinical predictions; Intensive care; prognostication; medical intensive care unit survival; medical intensive care unit; Survival; Resuscitation; Intensive care unit
• ISSN: 0090-3493; 1530-0293
• DOI: 10.1097/CCM.0b013e318205df9b

OBJECTIVE:We tested the accuracy of predictions of impending death for medical intensive care unit patients, offered daily by their professional medical caretakers.
DESIGN:For 560 medical intensive care unit patients, on each medical intensive care unit day, we asked their attending physicians, fellows, residents, and registered nurses one question“Do you think this patient will die in the hospital or survive to be discharged?”
RESULTS:We obtained >6,000 predictions on 2018 medical intensive care unit patient days. Seventy-five percent of MICU patients who stayed ≥4 days had discordant predictions; that is, at least one caretaker predicted survival, whereas others predicted death before discharge. Only 107 of 206 (52%) patients with a prediction of “death before discharge” actually died in hospital. This number rose to 66% (96 of 145) for patients with 1 day of corroborated (i.e., >1) prediction of “death,” and to 84% (79 of 94) with at least 1 unanimous day of predictions of death. However, although positive predictive value rose with increasingly stringent prediction criteria, sensitivity fell so that the area under the receiver-operator characteristic curve did not differ for single, corroborated, or unanimous predictions of death. Subsets of older (>65 yrs) and ventilated medical intensive care unit patients revealed parallel findings.
CONCLUSIONS:1) Roughly half of all medical intensive care unit patients predicted to die in hospital survived to discharge nonetheless. 2) More highly corroborated predictions had better predictive value; although, approximately 15% of patients survived unexpectedly, even when predicted to die by all medical caretakers.