Perceived poor prognosis can lead to withdrawal of life-sustaining therapies (WLST) in patients who might otherwise recover. We characterized clinicians’ approach to post-arrest prognostication in a multicenter clinical trial. Semi-structured interviews were conducted with clinicians who treated a comatose post-cardiac arrest patient enrolled in the Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial (NCT04217551). Two authors independently analyzed each interview using inductive and deductive coding. The clinician reported how they arrived at a prognosis for the specific patient. We summarized the frequency with which clinicians reported using objective diagnostics to formulate their prognosis, and compared the reported approaches to established guidelines. Each respondent provided demographic information and described local neuroprognostication practices. We interviewed 30 clinicians at 19 US hospitals. Most claimed adherence to local hospital neuroprognostication protocols ( = 19). Prognostication led to WLST for perceived poor neurological prognosis in 15/30 patients, of whom most showed inconsistencies with guidelines or trial recommendations, respectively. In 10/15 WLST cases, clinicians reported relying on multimodal testing. A prevalent theme was the use of “clinical gestalt,” defined as prognosticating based on a patient's overall appearance or a subjective impression in the absence of objective data. Many clinicians (21/30) reported using clinical gestalt for initial prognostication, with 9/21 expressing high confidence initially. Clinicians in our study state they follow neuroprognostication guidelines in general but often do not do so in actual practice. They reported clinical gestalt frequently informed early, highly confident prognostic judgments, and few objective tests changed initial impressions. Subjective prognostication may undermine well-designed trials.

中文翻译：

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临床医生预测参加美国临床试验的患者心脏骤停后结果的方法


感知到的不良预后可能会导致原本可能康复的患者放弃生命维持治疗 (WLST)。我们在一项多中心临床试验中描述了临床医生对逮捕后预测的方法。对参与“冷却时间对心脏骤停患者疗效的影响”(ICECAP) 试验 (NCT04217551) 的昏迷后心脏骤停患者进行治疗的临床医生进行了半结构化访谈。两位作者使用归纳和演绎编码独立分析了每次访谈。临床医生报告了他们如何得出特定患者的预后。我们总结了临床医生报告使用客观诊断来制定预后的频率，并将报告的方法与既定指南进行了比较。每个受访者都提供了人口统计信息并描述了当地的神经预测实践。我们采访了 19 家美国医院的 30 名临床医生。大多数人声称遵守当地医院的神经预测方案 (= 19)。 15/30 名患者因感知不良神经学预后而接受 WLST，其中大多数患者分别与指南或试验建议不一致。在 10/15 WLST 病例中，临床医生报告依赖于多模式测试。一个普遍的主题是使用“临床格式塔”，定义为在缺乏客观数据的情况下根据患者的整体外观或主观印象进行预测。许多临床医生 (21/30) 报告使用临床格式塔进行初步预测，其中 9/21 最初表示高度可信。我们研究中的临床医生表示，他们一般遵循神经预测指南，但在实际实践中往往不这样做。 他们报告说，临床格式塔经常提供早期、高度自信的预后判断，并且很少有客观测试改变最初的印象。主观预测可能会破坏精心设计的试验。