Uncertainty in Decision-Making: Critical Care, Imperfect Data

Margaret “Molly” Hayes, MD, associate director of the Internal Medicine Residency Training Program and assistant director of the medical intensive care unit at Beth Israel Deaconess Medical Center (BIDMC), discusses handling uncertainty in critical care decision-making.

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In the U.S., millions of patients are admitted to intensive care units (ICUs) annually. Compared with a standard hospital stay, critical care is 2.5 times as costly because ICUs are stacked with specialized staff, cutting-edge technology and critical care interventions aimed at stabilizing — and possibly saving — seriously ill or injured patients. Despite these resources, doctors often have limited time and incomplete information as they direct care. Yet within those limitations, they make life-and-death decisions.

Margaret “Molly” Hayes, MD, associate director of the Internal Medicine Residency Training Program and assistant director of the medical intensive care unit at Beth Israel Deaconess Medical Center (BIDMC) in Boston, is a pulmonary and critical care physician. She answers three questions about how care differs in the ICU, what she has learned from her patients and how to make critical decisions in the face of imperfect or conflicting data.

A conversation with Margaret “Molly” Hayes, MD


You’re an intensive care specialist. Please explain how caring for patients in the ICU differs from caring for patients in other parts of the health care system. ICU patients are sicker, of course, but what might people who are not clinicians not understand about the role of a doctor in the ICU?

Patients are admitted to the ICU because they are critically ill and have a high chance of dying. Our job as physicians is not only to help them get better, but also to help them and their families navigate this really challenging time. Frequently we don’t know the diagnosis initially, or we don’t know how one will respond to treatment: we are often faced with uncertainty. We must first accept this uncertainty ourselves and then help our patients and families understand and manage it. I think a lot of people don’t understand how prevalent uncertainty is in medicine, especially in the ICU. Our job as physicians is to not just help heal patients, but also help them through this difficult time. In addition to being a physician, we also often act as advisor and counselor.

 

Can you share a patient story that taught you a lesson you always carry with you?

This is a tough one. I truly believe that every patient I have ever cared for has taught me a lesson. I think the biggest theme is that patients are people. They are not just sick patients lying in a bed and our job is not just to prescribe interventions and medications. Our job is to listen to them, learn their stories and understand their perspectives so that we can best care for them. This helps us relate to our patients and build rapport, which makes having difficult conversations, explaining uncertainty and helping navigate life-and-death decision-making easier.

 

An intensive care doctor makes life-or-death treatment decisions based on reams of data from ever-advancing technology and information gleaned from patients, family members, and medical records. How do you handle conflicting or imperfect streams of data?

I think the best way is to admit uncertainty to yourself as a physician, to your team and, most importantly, to the patient and the family. There’s a lot of unknowns in critical care, especially when people are critically ill in the first 12 to 24 hours. During this time, we often don’t know what is making a patient so sick and there may be conflicting data. As physicians we are often in this balancing act of doing and thinking at the same time as data is coming in. We often have to make decisions in the moment with the information that we have. There’s never a perfect answer to any question. Sometimes we need to just act and figure it out later, and we have to admit that. When we don’t admit our uncertainty, or don’t acknowledge when things don’t fit, it can lead us down a wrong path that can potentially lead to harm.

 

Continue the conversation on Twitter by connecting with us @HMS_ExecEd or with Dr. Hayes @MHayes_MD.

— Steve Calechman

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