Patients denied admission to intensive care because of doctors' pessimism

Nov 2 2007

Doctors are overly pessimistic about the chances of survival for patients with COPD related attacks and, as a result, some patients may be denied admission to hospital for vital help, according to a study published on bmj.com.

COPD (chronic obstructive pulmonary disease) causes around 30,000 deaths a year in the UK and many patients who have COPD attacks can benefit from assisted ventilation, but they have to be admitted to an intensive care unit (ICU) to be intubated.

Researchers studied results from 92 intensive care and three respiratory high dependency units in the UK that dealt with 832 patients aged 45 years and over who had breathlessness, respiratory failure or change in mental status due to a COPD attack, asthma or both.

Information gathered over an 18-month period from a database covering 74% of UK ICUs said there was no significant difference in outcomes when comparing units that took part in the study and those that did not.

Overall, 517 (62%) patients survived to 180 days after the incident, but clinicians prognoses were pessimistic, predicting a survival rate of just 49%.

For the fifth of patients with the poorest prognosis according to the clinician, the predicted survival rate was 10% and the actual rate was 40%

The survival rates were 80% at discharge from ICU or high dependency units, 70% at discharge from hospital and 62% at 180 days after ICU admission.

The authors say: “Clinicians are generally pessimistic about the survival of patients with exacerbations of COPD and have particular problems in identifying those with poor prognosis. Patients might therefore be inappropriately excluded from intensive care and the chance of intubation on the basis of a false prediction of futility.”

In an accompanying editorial, US researchers point to a scarcity of intensive care resources as a possible explanation for these results.

They say that making decisions about admission to intensive care is complex, especially in the UK and southern Europe, where intensive care beds are often lacking. And they call for further studies to determine whether prognostic pessimism requires intervention aimed at doctors or at underlying healthcare systems that have inadequate provision of critical care services.

http://www.bma.org.uk