models and their methodological limits is useful to clinicians in framing the questions about end-of-life decisionmaking for themselves, the other caregivers, patients, and their families. The more accurate the predictive models and the narrower the confidence limits, the more useful they will be. What cutoff point will be the appropriate cutoff point to decide that no more should be done will remain, I believe, an individual decision informed by, but not made exclusively by, these increasingly accurate predictive models.

I am indebted to my colleague, Dr. Jennifer Daley, for her contributions to the ideas in this essay.


1. Chang, R.W.S. Individual Outcome Prediction Models for Intensive Care Units. Lancet 2(8655):143–146, 1989.

2. Daley J., Jencks S., Draper D. et al. Predicting Hospital-Associated mortality for Medicare Patients. Journal of the American Medical Association 260(24):3617–3624, 1988.

3. Diamond G.A. Future Imperfect: the Limitations of Clinical Predication Model and the Limits of Clinical Prediction. Journal of the American College of Cardiology 14(3):12A–22A, 1989.

4. Iezzoni L.I., Moskowitz M.A. A clinical assessment of Medisgroups. Journal of the American Medical Association 260(:31):3159–3163, 1988.

5. Iezzoni L.I. "Black box" medical information systems. A technology needing assessment. Journal of the American Medical Association 265(22):3006–3007, 1988.

6. Jancks S.F., Daley J., Draper D., et al. Interpreting hospital mortality date. The role of clinical risk adjustment. Journal of the American Medical Association 260(24):3611–3616 1988.

7. Knaus W.A., Draper E.A., Wagner D.P., et al. An evaluation of outcome from intensive care in major medical centers. Annals of Internal Medicine 104(3):410–418, 1986.

8. Knaus W.A., Wagner D.P., Draper E.A., Zimmerman J.E., Bergner M., Bastos P.G., et al. The APACHE III prognostic risk system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 100:1619–1636, 1991.

9. Knaus W.A., Wagner D.P., Zimmerman J.E., Draper E.A. Variations in mortality and length of stay in intensive care units. Annals of Internal Medicine 118:753–761, 1993.

10. Lemeshow S., Teres, Avrunin S.J., Pastides H. Predicting the outcome of intensive care patients. Journal of the American Statistical Association 83:348–356, 1988.

11. Pollack M.M., Ruttimann U.E., Getson P.R. Accurate prediction of the outcome of pediatric intensive care . New England Journal of Medicine 316:134–139, 1987.

12. Pollack M.M., Getson P.R., Ruttimann U.E., Steinhart C.M., Kanter R.K., Katz R.W., et al. Efficiency of intensive care. A comparative analysis of eight pediatric intensive care units. Journal of the American Medical Association 258:1481–1486, 1987.

13. Selker H.P. Systems for comparing actual and predicted mortality rates: characteristics to promote cooperation in improving hospital care. Annals of Internal Medicine 118:820–822, 1993.

14. Tores D., Lemeshow S., Avrunin S.J., Pastides H. Validation of the mortality prediction model for ICU patients. Critical Care Medicine 15:208–213, 1987.

15. Zimmerman J.E., Shorten S.M., Rousseau D.M., Duffy J., et al. Improving intensive care: Observations based on organizational case studies in nine intensive care units. A perspective, multicenter study. Critical Care Medicine 21(10):1443–1451, 1993.

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