I have written a lot about the importance of effective communication between the physician and the family in the ICU setting. Critically ill patients are often unable to make their own decisions regarding end-of-life care and this responsibility falls on the shoulders of their surrogate decision-makers.

The patient’s prognosis or chances for recovery is one of the most important questions being asked by the family. The surrogate has to know the likely prognosis and outcome to be able to make the decisions on behalf of the patient.

I often find communicating the prognosis for recovery to the family challenging. Sometime, it’s plain obvious to the healthcare providers that the patient is dying, yet the family simply “doesn’t get it”. Using techniques like repetition and associations might help to deliver the message. Yet, occasionally, the gap in the perception of prognosis persists.

A very interesting study conducted in California and published in the Critical Care Medicine Journal looks at the factors that, actually, influence the perception of prognosis by the surrogate decision makers.

Astoundingly, only 2% of surrogates base their view of the patient’s prognosis solely on the physician’s estimate. And 47% reported basing only part of their own prognosis on the physician’s opinion. Obviously, we are not doing a very good job.

According to this study multiple factors other than the physician’s opinion about the likely outcome influence the surrogate’s perception of the prognosis.

Twenty seven percent of surrogates considered the patient’s intrinsic qualities and will to live or die as a determinant of the outcome. I often hear: “she is a fighter…she will pull through” after I’ve just explained why the patient is not going to survive. Sometimes, I hear the opposite, people tell me “he’s lost his will to live a long time ago”.

The patient’s physical appearance and status, undoubtedly, affect the perception of prognosis. Many times I have been told by the family of the patient with a massive head injury that “he moved his arm… we think he is getting better”. Some motor reflexes happen on the level of the spinal cord and could still be present with a massive brain damage. On the contrary, when the patient is lying in bed cyanotic and mottled that appearance could help “persuade” the family the patient is dying.

Knowledge of the patient’s previous medical history and recovery might influence the decision as well. “He had pneumonia after he was treated for cancer before and survived. He is going to make it now”- the wife of the patient with metastatic lung cancer once told me.

Some family members and surrogates think that their mere presence at the bedside and encouragement might make a significant difference in the outcome. I never discourage anyone to visit the patient as long as it is not interfering with the medical care.

Personal beliefs and qualities like optimism and intuition have a huge influence on the perception of prognosis. Sometimes, I spend hours talking to the family again and again and at the end I hear something like “the God is looking over him…we believe the miracle will happen”. There is no problem with believing in God or a miracle as long as we not putting the patient through unnecessary procedures, surgeries or tests.

Being aware of and understanding the factors influencing the perception of prognosis by the family and surrogate decision-makers is extremely important for establishing an effective communication channel with the family and, ultimately, making the right decision for the patient.