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Being human, critical care practitioners are prone to develop conscious and unconscious stereotypes and biases in care. A self-fulfilling prophecy is a prediction that, having been made, carries with it a greater likelihood of becoming true due to the predictor’s actions and beliefs. Critical care has much evidence-based literature regarding clinical outcomes based on patient characteristics and these are likely to guide the practitioner, but these outcomes are not true for every patient, even when a binary outcome such as life or death is considered. Concerns are, that based on age, co-morbid conditions, socio-economic status, and other factors, practitioners may think and act in ways that increase positive or negative outcomes. For example, any common ICU conditions have very poor prognoses in the elderly: The mortality rate from severe sepsis/septic shock is over 50% among patients older than 80 years of age; the mortality for COVID-19 patients older than age 80 receiving mechanical ventilation has been reported as high as 89%. Both the published literature and anecdotal experience may cause the practitioner to be less likely to offer therapies that may improve outcomes.  Worse, these biases tend to spread throughout the entire care team, which may lead to less team communication, active care, personal attention, and poorer patient outcomes. Thus, fulfilling the prophecy of a cycle of illness.

Conscious awareness of a self-fulfilling prophecy is an important goal among critical care professionals. In particular, the practitioner should be attentive to the possibility of conscious or subconscious premature determination or bias regarding an individual patient’s prognosis. This is particularly concerning when objective studies of these situations are limited, and practitioners may be influenced by intuitive conclusions rather than unbiased facts. These attitudes are also likely to affect the feelings of family members and depending on the situation, make it more or less likely for families to wish for aggressive versus comfort-based care.

Whereas negative self-fulfilling prophecies are to be cautioned against, positive self-fulfilling prophecies also occur and may benefit the patient. When the critical care team has positive expectations, this may lead to a ‘virtuous cycle’ of increased communication with patients and families, active therapies, treatments, and emotional support, which are all variables that are likely to improve outcomes.

There is much evidence-based literature dealing with the likelihood of acceptable or good outcomes with many critically ill or injured patients, based on age, co-morbid conditions, or other personal characteristics. It is wise for practitioners to be generally familiar with some of these findings and it is likely appropriate to discuss these data with patients and families. Indeed, these data may be important factors in deciding the possibility of limitations of life-sustaining treatment among critically ill patients. Patients, however, may have certain omitted characteristics that considerably confound these prognoses. As previously noted, severe traumatic brain injury (TBI) is a condition with well-documented outcomes and prognoses but anecdotally seems to be associated with negative self-fulfilling prophecies.

Conscious or subconscious stereotypes and biases, even if well-founded, continue to be associated with self-fulfilling prophecies, which potentially lead to both detriments and benefits among our critically ill patients. As with other concerns, the best approach to the issue is to acknowledge the problem exists, so that practitioners may guard against negative stereotypes and so that our patients and families may receive the advantages of more appropriate critical and palliative care.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Physician’s Weekly, their employees, and affiliates.