In this study, we use the question "would you be surprised if this patient died" to explore how residents think about their critically ill patients. This inquiry appears to stimulate reflection and dialogue about the potential for a patient's death and, as hinted by one resident's response, may be less threatening than "is your patient dying?" As such, this approach may offer physicians a "safer space" to acknowledge the possibility of death by encouraging reflection without impugning a physician's intentions or competence.
These encounters provide preliminary insight into how residents think about prognosis when caring for seriously ill, hospitalised patients. Residents appear to frequently utilise clinical course – whether a patient is getting better or worse – to determine the likelihood of a patient's death. This may be an important finding, as this iterative-type approach is unlike common prognosticating instruments such as the APACHE or SUPPORT score, which attempt to determine prognosis based on a single evaluation [11, 12]. Traditional prognostic tools might also fail to capture other elements cited by residents when assessing a patient's likelihood of dying: prior survival under similar conditions, reversibility of the disease, and sudden onset of an acute illness. Previous authors have noted that quantitative models are rarely used in clinical practice  – in part, because clinicians may not know how to use them in a meaningful and effective way , and such models apply to populations and fail to account for the uniqueness of the individual . While the accuracy of the resident-reported elements remains unknown, perhaps prognostic models that account for prior experience and trajectory of the illness may be more clinical useful and intuitively understandable to patients, families and providers.
This study identifies several potential barriers to management changes after recognising that a patient might be dying. Understanding these barriers – whether real or perceived – may be important in efforts to improve ICU care. Multiple residents cited "lack of time" as a barrier to changing management once their patient had been identified as possibly dying. This may reflect the current culture of medical training: in one prior study, 80% of surgical residents reported feeling constrained by time when caring for terminally ill patients and their families . Alternatively, residents might be using lack of time as an excuse – either consciously or otherwise – to avoid difficult, seemingly time-intensive conversations with patients and families. As such, this perceived barrier might highlight a potential misconception that not talking with patients takes less time. A time flow study might help to clarify the validity of this perception.
Residents may not recognise or explicitly express other important, real barriers. For example, the cited responses suggest that residents seek to present themselves as self-governing, autonomous decision-makers, when in fact they may be strongly influenced by the cultural milieu of the ICU. Residents may fail to recognise or admit the importance of peer pressure or "conforming to the norm" in their decision-making. Furthermore, the ICU cultural milieu may profoundly impact how residents prioritise responsibilities. Balancing competing demands within a "cult of curability" may encourage physicians to evaluate success on the basis of curing, rather than on the basis of providing the best care for patients . In such a system, it is easy to imagine how a resident's reluctance to propose alternative care approaches could result from intimidation by the accepted system rather than her own self-acknowledged lack of experience. Feelings of increased stress and less collegial support when managing dying patients might further contribute to this apprehension .
Another potential barrier is suggested by residents' frequent references to "doing everything". It is often misleadingly assumed in this phrase that there exists some common understanding of what "everything" entails. While some residents may have had detailed conversation with patients and families, resident responses seem to suggest otherwise – that care goals were often poorly understood. Statements like "we are doing everything" or "there is nothing more we can do" likely mirror the culture of medical training. McCue, in a 1995 JAMA article, describes medicine as a "culture of action" – it is better to do something (more tests, another medication) than to do nothing, even if the action is known to have no benefit . In one study, almost half (47%) of physicians and nurses surveyed reported acting contrary to conscience in providing care to the terminally ill, with four times as many providing overly burdensome treatment than undertreatment . The propensity to refer to "everything", even in cases with specific known goals, might inadvertently promote futile attempts to prolong life and deflect attention away from patients' pain and suffering. Understanding why we choose such language, whether due to a poor understanding of specific goals or simply a convenient construct for describing curative care, might help in the design of practical interventions that would promote more comprehensive care.
Some residents were quite hesitant about answering questions regarding changing management. While this open-ended inquiry is inherently ambiguous, these apprehensive responses might also suggest residents' discomfort with changing a plan recommended by supervising physicians. Alternatively, the hesitation may also highlight residents' discomfort with managing patients who may be dying. Medical education traditionally focuses on training physicians to diagnose, cure and prolong life, with only minimum attention given to the techniques of caring for the patient for whom cure is of less relevance [20, 21]. An ABIM survey of more than 1400 IM residents found that 72% reported receiving adequate training in managing pain and other symptoms, 62% in breaking bad news to patients, 38% in educating the patient and family about the dying process and 32% in responding to patients who request assistance in dying [22, 23]. Further heightening apprehension might be residents' emotional inexperience, especially in an environment where the emotional needs of care providers may be inadequately addressed.
Likewise, physicians may also lack the skill to recognise or elicit the needs of patients and their families. Eric Cassell writes that this lack of recognition and treatment of suffering does not come about because of an absence of compassion or concern, but more often results from physicians' poor diagnostic and therapeutic knowledge and skills about persons. Cassell challenges physicians to learn and teach methods in "empathic attentiveness" in order to know patients as individual persons well enough to understand the origin of their suffering and ultimately its best treatment .
How might the information from this study help to improve patient care? First, this study hints that at least some residents may be more inclined to think about the concurrent palliative needs of patients and families after considering the possibility that their patients may be dying. The surprise question, as such, could be a direct means to impacting breadth of care. Future studies might prospectively examine variation in care management following this routine inquiry coupled with follow-up questions such as "Has asking this question changed your opinion about whether the patient might dying?" or "Will you change your management of the patient because I asked this question?" As Eric Cassell notes, the act of consciously thinking about information, whatever its origins – numbers on a printout, a report of pain, or in this case, the possibility for death – makes it objective, an object of consciousness .
Second, clinical course and other factors appear to influence communication – knowingly or not – with patients and their families. Some of these residents appear to postpone or avoid potentially goal-defining conversations with patients and families if the chance for immediate death seems unlikely or remote. As many patients and families may embrace an approach of "doing everything" in cases where the disease trajectory is not straightforward, postponing conversations regarding goals of care may effectively limit care options until no more curative treatments remain and such discussions become a practical necessity. More in-depth studies are needed to better understand how and to what extent these factors alter decision-and communication in the ICU setting.
This study has multiple limitations. First, whether the findings from this small exploratory study are transferable to a broader sample of interns and residents is unknown. Although this study was integrated into a real-world, established setting, the core question may not provide similar insightful dialogue in other venues. From at least the general perspective of medical education, these observations seem relevant. While the credibility of the study is enhanced through the facilitating faculty's 2 years of EDP field experience, member checking – reviews from the participating residents – and independent peer examination would have increased validity . More purposive sampling governed by emerging insights would have helped to clarify details of the promising themes. Next, it is unlikely, given the limited encounters, that saturation of resident responses was achieved. Although no new themes emerged during the last several interactions, we chose to not to collect additional data, in part, because the primary goal of this study – to provide a basic, preliminary framework into how residents approach decisions in the ICU – had been achieved. We believe these preliminary data support more extensive exploration of identified themes. While following the question flow diagram provided a consistent inquiry, the dependability of the process may have been compromised by not specifying a time frame with the question "would you be surprised"? An additional assessment of study dependability or confirmability through audit would have improved the trustworthiness of these data. Finally, we did not account for differences between patients' severity of illness, variations in residents' critical or palliative care experience, comfort in caring for dying patients or the influence of the fellow or attending physician on management decisions. Capturing data on these other factors would have helped define their potential influence on resident responses.