Should Clinicans Give Recommendations?

I was taught to give recommendations to seriously ill patients and family members facing tough choices.  This was probably best taught to me via the following analogy. 

Let’s say you go to Best Buy, and ask to buy a computer, and the store person says, “Do you want SDRAM or GDDDR5 Ram?  Do you want a Thunderbolt port or a Firewire port?  Do you want a dual core or a quad core processor?”  Unless you’re a total computer geek, you’re going to feel lost, and unable to make these decisions.  On the other hand, the store person could say, “What do you want to do with the computer?  Do you need it to be portable?  Are you going to use it for intensive graphics or gaming?  Based on your needs, I think the best option for you is…”

Similarly, I was taught to elicit patient and family goals and preferences, and as the medical expert, offer a recommendation.  “Based on what you’ve told me about your mother – her preference not to live on machines – it seems to me the best course of care is most likely to focus on keeping her as comfortable as possible.  The best place for that care is in a setting like our hospice, not this ICU.”

However, a 2009 study by Doug White (formerly at UCSF, now at the University of Pittsburgh) has thrown into question the practice and policy of major Critical Care Societies of routinely giving a recommendation. 

Doug and colleagues interviewed 165 surrogates of seriously ill ICU patients.  He showed them a video tape of a physician surrogate interaction with two possible endings.  In one ending the physician gives a recommendation, in the other, the physician does not.  For a small amount of context, the surrogate is the daughter of a 72 year old man with a pneumonia and kidney failure hooked up to a breathing machine in the ICU for two weeks.  I don’t have the actual video of the two possible endings, so I’ve converted them into this video of my favorite talking bears.  In this video, the ending without a recommendation is first, followed by a short pause, then the ending with the recommendation.  For the actual study, the order of the endings was randomized (some saw the recommendation first, some saw the video without the recommendation first). 

Here are the findings from the study:

• 56% preferred to receive a recommendation.  Reasons given included: it’s the physician’s role to give a recommendation, it lifts the burden off surrogates, and it’s the physician’s responsibility as the medical expert.
• 42% preferred not to receive a recommendation.  Reasons given included: it’s not the physician’s role to give a recommendation, it could be detrimental to the relationship with the physician if there is disagreement, and it would hinder the families ability to come to a decision on their own

This was surprising to me!  Now, when we discussed this article at our last Palliative Care Journal club, people had issues with a number of aspects of the study – were these surrogates projecting their own experiences on the video encounter, the lack of open ended exploratory questioning, and the fact that the recommendation was either given or not given, rather than offered and accepted or declined. 

Still, most likely there are probably a minority of surrogates who do not and will not appreciate a recommendation.  The take home lesson for me is that a recommendation should not be routinely given.  Rather, a recommendation should be offered, and the reasons for or against, or for ambivalence about the recommendation should be explored. 

What do you think?  What should we do?  Would you want a recommendation?  What would you do if your doctor asked you?  (too much Dr. Seuss, I know, sounds like the ending to Cat in the Hat.  What can I say? the kids are 3 and 5).

by: Alex Smith