How ICU clinicians document ‘Futility’: A 10-year analysis of critical care notes using natural language processing notes

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BACKGROUND: ICU patients frequently receive treatments clinicians perceive are futile which can cause conflict between clinicians, patients and families. Medical futility lacks a consensus definition, yet this ambiguous and contentious term is used in medical notes. RESEARCH QUESTION: What themes are associated with futility mentions in ICU notes? How have themes' frequencies changed over time? STUDY DESIGN/METHODS: Mixed methods study of ICU notes (e.g., H&P, progress notes) written by clinicians (e.g., physicians, nurses) for adult patients at a large hospital system from 2010 to 2020. Neural network models identified terms most associated with "futile" or "futility." Distributional semantic analysis grouped terms into themes. Regression modeling explored longitudinal changes in themes' frequencies. RESULTS: Across 2,460,169 notes for 9912 patients, the annual average count of unique notes with futility mentions was 137 per 100,000 and unchanged from 2010 to 2020. 8 themes were identified among terms most associated with the words "futile" or "futility." The most represented themes were Decision Making (annual average 18% [95% CI: 16%-19%]), Assessing, Prognosticating, and End-of-Life Outcomes (15%, 13%-16%), and Identifying Sentiments (13%, 10%-15%). Recording Code Status was the least represented theme in 2010 (4%) and increased over time (9% in 2020, P = 0.001). INTERPRETATION: Use of futility was rare and stable across a decade of ICU notes. Semantic analysis indicates clinicians use futility in heterogeneous contexts. Changes in themes' frequencies may reflect clinicians' evolving conceptions of medical futility. These findings could guide development of EHR-based interventions to address perceived futile treatments which contribute to clinicians' moral distress.

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