• Amber E Barnato, Heather E Hsu, Cindy L Bryce, Judith R Lave, Lillian L Emlet, Derek C Angus, and Robert M Arnold.
• University of Pittsburgh, Pittsburgh, PA, USA. aeb2@pitt.edu
• Crit. Care Med. 2008 Dec 1;36(12):3156-63.

ObjectiveTo determine the feasibility of high-fidelity simulation for studying variation in intensive care unit admission decision making for critically ill elders with end-stage cancer.DesignMixed qualitative and quantitative analysis of physician subjects participating in a simulation scenario using hospital set, actors, medical chart, and vital signs tracings. The simulation depicted a 78-yr-old man with metastatic gastric cancer, life-threatening hypoxia most likely attributable to cancer progression, and stable preferences to avoid intensive care unit admission and intubation. Two independent raters assessed the simulations and subjects completed a postsimulation web-based survey and debriefing interview.SettingPeter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh.SubjectsTwenty-seven hospital-based attending physicians, including 6 emergency physicians, 13 hospitalists, and 8 intensivists.Measurements And Main ResultsOutcomes included qualitative report of clinical verisimilitude during the debriefing interview, survey-reported diagnosis and prognosis, and observed treatment decisions. Independent variables included physician demographics, risk attitude, and reactions to uncertainty. All (100%) reported that the case and simulation were highly realistic, and their diagnostic and prognostic assessments were consistent with our intent. Eight physicians (29.6%) admitted the patient to the intensive care unit. Among the eight physicians who admitted the patient to the intensive care unit, three (37%) initiated palliation, two (25%) documented the patient's code status (do not intubate/do not resuscitate), and one intubated the patient. Among the 19 physicians who did not admit the patient to the intensive care unit, 13 (68%) initiated palliation and 5 (42%) documented code status. Intensivists and emergency physicians (p = 0.048) were more likely to admit the patient to the intensive care unit. Years since medical school graduation were inversely associated with the initiation of palliative care (p = 0.043).ConclusionsSimulation can reproduce the decision context of intensive care unit triage for a critically ill patient with terminal illness. When faced with an identical patient, hospital-based physicians from the same institution vary significantly in their treatment decisions.

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