Neurocritical Care

, 11:345 | Cite as

Profiles of Neurological Outcome Prediction Among Intensivists

  • Eric RacineEmail author
  • Marie-Josée Dion
  • Christine A. C. Wijman
  • Judy Illes
  • Maarten G. Lansberg
Original Article



Advances in intensive care medicine have increased survival rates of patients with critical neurological conditions. The focus of prognostication for such patients is therefore shifting from predicting chances of survival to meaningful neurological recovery. This study assessed the variability in long-term outcome predictions among physicians and aimed to identify factors that may account for this variability.


Based on a clinical vignette describing a comatose patient suffering from post-anoxic brain injury intensivists were asked in a semi-structured interview about the patient’s specific neurological prognosis and about prognostication in general. Qualitative research methods were used to identify areas of variability in prognostication and to classify physicians according to specific prognostication profiles. Quantitative statistics were used to assess for associations between prognostication profiles and physicians’ demographic and practice characteristics.


Eighteen intensivists participated. Functional outcome predictions varied along an evaluative dimension (fair/good–poor) and a confidence dimension (certain–uncertain). More experienced physicians tended to be more pessimistic about the patient’s functional outcome and more certain of their prognosis. Attitudes toward quality of life varied along an evaluative dimension (good–poor) and a “style” dimension (objective–subjective). Older and more experienced physicians were more likely to express objective judgments of quality of life and to predict a worse quality of life for the patient than their younger and less experienced counterparts.


Various prognostication profiles exist among intensivists. These may be dictated by factors such as physicians’ age and clinical experience. Awareness of these associations may be a first step to more uniform prognostication.


Prognosis Coma Critical care Ethics Neurology Neuroethics 



The authors would like to acknowledge the contribution of all volunteer participants for their time and openness as well as Tessa Watt for research assistance. Support for this research comes from the Social Sciences and Humanities Research Council of Canada (E.R.) the Institut de recherches cliniques de Montréal (E.R.), the Fonds de la recherche en santé du Québec (E.R.), the Canadian Institutes of Health Research (E.R.), and the National Institutes of Health/National Institute of Neurological Disorders and Stroke, (R01 #NS045831, J.I. and K23 NS051372, M.L.).

Supplementary material

12028_2009_9225_MOESM1_ESM.doc (29 kb)
Supplementary material 1 (DOC 29 kb)


  1. 1.
    Razvi SSM, Bone I. Neurological consultation in the medical intensive care unit. J Neurol Neurosurg Psychiatr. 2003;74(Suppl III):iii16–23. doi: 10.1136/jnnp.74.suppl_3.iii16.PubMedGoogle Scholar
  2. 2.
    Bernat JL. Ethical aspects of determining and communicating prognosis in critical care. Neurocrit Care. 2004;1:107–17. doi: 10.1385/NCC:1:1:107.CrossRefPubMedGoogle Scholar
  3. 3.
    Kua JKH, Parker G, Lee C, Jorm AF. Beliefs about outcomes for mental disorders: a comparative study of primary health practitioners and psychiatrists in Singapore. Singapore Med J. 2000;41(11):542–7.PubMedGoogle Scholar
  4. 4.
    Robertson DW. Ethical theory, ethnography, and differences between doctors and nurses in approaches to patient care. J Med Ethics. 1996;22:292–9. doi: 10.1136/jme.22.5.292.CrossRefPubMedGoogle Scholar
  5. 5.
    Creswell JW. Qualitative inquiry and research design: choosing among five approaches. Thousand Oaks, CA: Sage; 2007.Google Scholar
  6. 6.
    Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;9(9):1277–88.CrossRefGoogle Scholar
  7. 7.
    Forman J, Damschroder L. Qualitative content analysis. Adv Bioeth. 2008;11(9):39–63.Google Scholar
  8. 8.
    Giacomini MK, Cook DJ. Users’ guides to the medical literature: XXIII. Qualitative research in health care B. What are the results and how do they help me care for my patients? Evidence-based medicine working group. JAMA. 2000;284:478–82. doi: 10.1001/jama.284.4.478.CrossRefPubMedGoogle Scholar
  9. 9.
    Giacomini MK, Cook DJ. Users’ guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence-based medicine working group. JAMA. 2000;284:357–62. doi: 10.1001/jama.284.3.357.CrossRefPubMedGoogle Scholar
  10. 10.
    Jeffrey D. Patient-centred ethics and communication at the end of life. Oxford: Radcliffe Publishing; 2005.Google Scholar
  11. 11.
    Keenan SP, Busche KD, Chen LM, Esmail R, Inman KJ, Sibbald WJ. Withdrawal and withholding of life support in the intensive care unit: a comparison of teaching and community hospitals. The Southwestern Ontario Critical Care Research Network. Crit Care Med. 1998;26:245–51. doi: 10.1097/00003246-199802000-00018.CrossRefPubMedGoogle Scholar
  12. 12.
    Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158:1163–7.PubMedGoogle Scholar
  13. 13.
    Cook DJ, Guyatt GH, Jaeschke R, et al. Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill. Canadian Critical Care Trials Group. JAMA. 1995;273:703–8. doi: 10.1001/jama.273.9.703.CrossRefPubMedGoogle Scholar
  14. 14.
    Asch DA, Faber-Langendoen K, Shea JA, Christakis NA. The sequence of withdrawing life-sustaining treatment from patients. Am J Med. 1999;107:153–6. doi: 10.1016/S0002-9343(99)00198-9.CrossRefPubMedGoogle Scholar
  15. 15.
    Cook DJ, Giacomini M, Johnson N, Willms D. Life support in the intensive care unit: a qualitative investigation of technological purposes. Canadian Critical Care Trials Group. CMAJ. 1999;161:1109–13.PubMedGoogle Scholar
  16. 16.
    Marcin JP, Pollack MM, Patel KM, Sprague BM, Ruttimann UE. Prognostication and certainty in the pediatric intensive care unit. Pediatrics. 1999;104:868–73. doi: 10.1542/peds.104.4.868.CrossRefPubMedGoogle Scholar
  17. 17.
    Marcin JP, Pretzlaff RK, Pollack MM, Patel KM, Ruttimann UE. Certainty and mortality prediction in critically ill children. J Med Ethics. 2004;30:304–7. doi: 10.1136/jme.2002.001537.CrossRefPubMedGoogle Scholar
  18. 18.
    Rocker GM, Cook DJ, Shemie SD. Practice variation in end of life care in the ICU: implications for patients with severe brain injury. Can J Anaesth. 2006;53:814–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Rebagliato M, Cuttini M, Broggin L, et al. Neonatal end-of-life decision making: physicians’ attitudes and relationship with self-reported practices in 10 European countries. JAMA. 2000;284:2451–9. doi: 10.1001/jama.284.19.2451.CrossRefPubMedGoogle Scholar
  20. 20.
    Randolph AG, Zollo MB, Wigton RS, Yeh TS. Factors explaining variability among caregivers in the intent to restrict life-support interventions in a pediatric intensive care unit. Crit Care Med. 1997;25:435–9. doi: 10.1097/00003246-199703000-00011.CrossRefPubMedGoogle Scholar
  21. 21.
    Veloski J, Tai S, Evans AS, Nash DB. Clinical vignette-based surveys: a tool for assessing physician practice variation. Am J Med Qual. 2005;20:151–7. doi: 10.1177/1062860605274520.CrossRefPubMedGoogle Scholar
  22. 22.
    Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of three methods for measuring quality. JAMA. 2000;283:1715–22. doi: 10.1001/jama.283.13.1715.CrossRefPubMedGoogle Scholar

Copyright information

© Humana Press Inc. 2009

Authors and Affiliations

  • Eric Racine
    • 1
    • 2
    • 3
    Email author
  • Marie-Josée Dion
    • 1
  • Christine A. C. Wijman
    • 4
    • 5
  • Judy Illes
    • 6
    • 7
    • 8
  • Maarten G. Lansberg
    • 4
    • 5
  1. 1.Neuroethics Research UnitInstitut de recherches cliniques de MontréalMontrealCanada
  2. 2.Department of MedicineUniversity of MontrealMontrealCanada
  3. 3.Department of Neurology and Neurosurgery and Biomedical Ethics UnitMcGill UniversityMontrealCanada
  4. 4.Department of Neurology and Neurological SciencesStanford UniversityStanfordUSA
  5. 5.Stanford Stroke CenterStanford UniversityStanfordUSA
  6. 6.Center for Biomedical EthicsStanford UniversityStanfordUSA
  7. 7.Department of PediatricsStanford UniversityStanfordUSA
  8. 8.National Core for NeuroethicsUniversity of British ColumbiaVancouverCanada

Personalised recommendations