Content area
Full Text
Four principal factors have been identified as determinants of the observed variation in healthcare practice: patient, clinician, institution, and environment. 1 Keeping all other factors constant, the knowledge that different doctors will make the same decision about the same patient under identical conditions is reassuring. If, however, the decision varies according to who makes it, then it is reasonable to question whether the principles of equity and quality of care are being upheld. It is also imperative to look into the causes of such variation.
Chronic obstructive pulmonary disease (COPD) is a progressive and irreversible respiratory disease with death rates similar to that of lung cancer. 2 Disease progression is often characterised by a series of exacerbations which may require ventilatory support. If such support is not provided, the patient may die from respiratory failure. Patients with COPD account for about 2.5% of critical care admissions in the UK. 3 Admission to the intensive care unit (ICU) and mechanical ventilation can return some COPD patients to their pre-existing level of functioning. If, however, the terminal phase of the disease has been reached, ventilation will be futile and will prolong the process of dying. Furthermore, mechanical ventilation is not without disadvantages and risks. 4 Clinicians therefore need to assess if the patient is likely to receive "sustained benefit in terms of quality and length of life" from ICU admission. 5
Outcome prediction is difficult before ventilation is started 6 and the accuracy of clinicians in outcome prediction has been questioned. 7- 9 A study by Pearlman and colleagues 10, 11 of decision making in this area, using one vignette of an elderly debilitated patient with COPD in extremis, found that survival estimates ranged from 1 month to 5 years and were highly correlated with treatment decisions. When the 205 US doctors who participated in the study were asked to explain their decision, non-intubators most frequently referred to the patient's poor quality of life and the terminal stage of the disease while intubators most frequently talked about the clinical situation being reversible. Since explanations and survival estimates were given after the decision had been made, we cannot assume that they were more than justifications. Questions therefore remain as to the source of the observed differences.
ICUs...