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Medical decision making : an international journal of the Society for Medical Decision Making


Academic Medical Centers; Adult; Aged; Attitude of Health Personnel; Clinical Decision-Making; Critical Care; Female; Hospitals; Humans; Interviews as Topic; Intubation; Male; Middle Aged; Models, Psychological; Patient Simulation; Physician-Patient Relations; Physicians; Practice Patterns, Physicians'; Terminal Care; Terminally Ill; United States; advance directives; critical care; end-of-life; hospital; intubation; mechanical ventilation; mental model; patient preferences; patient-physician communication; shared decision making; simulation; terminal care


BACKGROUND: Variation in the intensity of acute care treatment at the end of life is influenced more strongly by hospital and provider characteristics than patient preferences.

OBJECTIVE: We sought to describe physicians' mental models (i.e., thought processes) when encountering a simulated critically and terminally ill older patient, and to compare those models based on whether their treatment plan was patient preference-concordant or preference-discordant.

METHODS: Seventy-three hospital-based physicians from 3 academic medical centers engaged in a simulated patient encounter and completed a mental model interview while watching the video recording of their encounter. We used an "expert" model to code the interviews. We then used Kruskal-Wallis tests to compare the weighted mental model themes of physicians who provided preference-concordant treatment with those who provided preference-discordant treatment.

RESULTS: Sixty-six (90%) physicians provided preference-concordant treatment and 7 (10%) provided preference-discordant treatment (i.e., they intubated the patient). Physicians who intubated the patient were more likely to emphasize the reversible and emergent nature of the patient situation (z = -2.111, P = 0.035), their own comfort (z = -2.764, P = 0.006), and rarely focused on explicit patient preferences (z = 2.380, P = 0.017).

LIMITATIONS: Post-decisional interviewing with audio/video prompting may induce hindsight bias. The expert model has not yet been validated and may not be exhaustive. The small sample size limits generalizability and power.

CONCLUSIONS: Hospital-based physicians providing preference-discordant used a different mental model for decision making for a critically and terminally ill simulated case. These differences may offer targets for future interventions to promote preference-concordant care for seriously ill patients.


Palliative Care