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Maley and colleagues provide a provocative argument in relation to how we make decisions about end of life. The premise was relatively clear: predictive models have a significant limitation in that they are bound by the decisions made in previous 'similar' cases. As such, the true potential outcomes are unknown. Indeed, would the authors consider the possibility of a 'self-fulfilling prophecy' scenario, whereby the previous decisions - particularly where the decision for comfort measures were taken - reinforce future decisions?
The article was fascinating and well written, however the proposed mechanism for implementing the causal effect modelling was not clear, at least to the non-statistically informed clinician. The idea of running predictive hypothetical clinical trials is fascinating. The seeming potential to provide greater clarity for the most difficult decision in medicine is intriguing and, certainly this clinician, would be most appreciative of further exploration and explanation of the methods involved. Continuing a real-life scenario and discussing how close we are to such modelling being applicable to real cases - future studies - would also be much appreciated.