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Table 2 Representative resident responses by category and domain

From: Would you be surprised if this patient died?: Preliminary exploration of first and second year residents' approach to care decisions in critically ill patients

CATEGORY 1: Why surprised?
Domain Example
Presence of a reversible disease • "...Because initially it was thought to be a hypersensitivity pneumonitis – a reversible disease. We weren't really thinking about her dying."
Rapid onset of an acute illness • "You know, it happens so quickly sometimes. She was all right a week ago, and suddenly she's here in the ICU. We've been mostly concentrating on making her better."
Improving clinical course • "Surprised? Yeah – I guess so... I think she's much better."
  • "Maybe we did at first, but his enzymes are coming down now. I think it's probably more likely that he'll wake up."
  • "I would be surprised then too. Nothing was that much different – she was doing OK."
Prior survival under similar circumstances • "...He has been in before, though, for dobutamine and he's done fine. I think that's why they continue to want everything done."
CATEGORY 2: Why not surprised?
Domain Example
Worsening clinical course • "I wouldn't be surprised. She's [now] been intubated for the last three or four days."
 Facilitator: "Could it be that she is now dying?"
  Resident: "Dying? Well, she's definitely getting worse. I'm not sure I'd say she's dying."
  Facilitator: "Would you be surprised if she died?"
  Resident: "No...not when you ask it that way."
CATEGORY 3: Changes in management
Domain Example
Clarifying goals • "When you're talking about working up – micromanaging – every little thing, you should probably figure out [what] the family and patient would really want. ... I think [that] talks with the family would clarify these things."
Improving communication with patients and families • "Yeah, I would probably spend more time with the patient and the family – and [I would] listen to their story."
Spending more time with patients/ ordering fewer labs • "...I'd probably spend more time with the patient – you know, getting to know his wishes. And I'd order less labs – since it wouldn't make much difference."
CATEGORY 4: Barriers to changes in management
Domain Example
Limited time • "And you don't have time – unless you're doing an ethical rotation where you can sit down and talk to a patient for an hour and a half. Usually you get done with everything and [realize], "oh, I didn't ask them about cor status" – and what they would want done. ...You can't explain what all the options are."
Competing clinical priorities • "...There's a bunch of family things that I need to follow up on. And those end up being, in my mind, the most important – but the nurses are like "you've got to have the morning labs and the x-ray requests filled out." I'm just trying to play catch-up."
  • "Well, just the intubation...just keeping someone on an FiO2 of over 80 percent and the damage it causes. She'll get much worse – [and] we'll have to address those problems when they come. I'm hoping not, though."
Not knowing a patient • "Well, for me, I came on the service with ten new patients and we were on call... The next day I was off... So I just feel I still don't really know these patients."
Limited knowledge and experience • "And it's also hard for me – as an intern. ... And I don't feel like I know enough about ICU medicine – I have no idea what chronic acetaminophen toxicity...what the outcome is. ...If I knew more about people's outcomes, I would be pushing one way or the other."
The presence of diagnostic or prognostic uncertainty Resident: "...So the problem is she was found to have a normal CT scan, and now has diffuse cerebral oedema. We don't know how much of it is contributing to her mental status."
  Nurse: "Is the pain service involved?"
  Resident: "No, and I guess the fear is that we narc her too much to know what really is going on with her mental status. I'm not really comfortable doing that ..."
Unclear goals • " I spoke with the aunt on the day after she was admitted and, of course, they want everything done.... I think they are blinded to the fact that this does not look good, given her mental status. ...And I don't know how much she knows, but they want everything done..."
  • "...I haven't talked with her for a couple of days, but I know that she sees that her mom is doing better. It's still not clear if she is the best one to be making decisions, but the family is still working that out. We haven't had a family meeting since last week – mostly because she is doing so much better."
  • "... We're focusing on making her better. ...I'm not sure if the family completely agrees, but for now they see how she's improving with what's been done. ...There's really not many decisions to make unless she gets sicker again."