Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

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Abstract

Purpose

Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown.

Methods

In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis.

Results

Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good ( n = 12, 18%) and poor ( n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) ( P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with ( n = 12, 18%) or without ( n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former.

Conclusion

Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5231-8) contains supplementary material, which is available to authorized users.

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To describe trends in the aggressiveness of end-of-life (EOL) cancer care in a universal health care system in Ontario, Canada, between 1993 and 2004, and to compare with findings reported in the United States. A population-based, retrospective, cohort study that used administrative data linked to registry data. Aggressiveness of EOL care was defined as the occurrence of at least one of the following indicators: last dose of chemotherapy received within 14 days of death; more than one emergency department (ED) visit within 30 days of death; more than one hospitalization within 30 days of death; or at least one intensive care unit (ICU) admission within 30 days of death. Among 227,161 patients, 22.4% experienced at least one incident of potentially aggressive EOL cancer care. Multivariable analyses showed that with each successive year, patients were significantly more likely to encounter some aggressive intervention (odds ratio, 1.01; 95% CI, 1.01 to 1.02). Multiple emergency department (ED) visits, ICU admissions, and chemotherapy use increased significantly over time, whereas multiple hospital admissions declined (P < .05). Patients were more likely to receive aggressive EOL care if they were men, were younger, lived in rural regions, had a higher level of comorbidity, or had breast, lung, or hematologic malignancies. Chemotherapy and ICU utilization were lower in Ontario than in the United States. Aggressiveness of cancer care near the EOL is increasing over time in Ontario, Canada, although overall rates were lower than in the United States. Health system characteristics and patient or physician cultural factors may play a role in the observed differences.

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Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians.

Ruth Piers (2011)

Clinicians in intensive care units (ICUs) who perceive the care they provide as inappropriate experience moral distress and are at risk for burnout. This situation may jeopardize patient quality of care and increase staff turnover. To determine the prevalence of perceived inappropriateness of care among ICU clinicians and to identify patient-related situations, personal characteristics, and work-related characteristics associated with perceived inappropriateness of care. Cross-sectional evaluation on May 11, 2010, of 82 adult ICUs in 9 European countries and Israel. Participants were 1953 ICU nurses and physicians providing bedside care. Perceived inappropriateness of care, defined as a specific patient-care situation in which the clinician acts in a manner contrary to his or her personal and professional beliefs, as assessed using a questionnaire designed for the study. Of 1651 respondents (median response rate, 93% overall; interquartile range, 82%-100% [medians 93% among nurses and 100% among physicians]), perceived inappropriateness of care in at least 1 patient was reported by 439 clinicians overall (27%; 95% CI, 24%-29%), 300 of 1218 were nurses (25%), 132 of 407 were physicians (32%), and 26 had missing answers describing job title. Of these 439 individuals, 397 reported 445 situations associated with perceived inappropriateness of care. The most common reports were perceived disproportionate care (290 situations [65%; 95% CI, 58%-73%], of which "too much care" was reported in 89% of situations, followed by "other patients would benefit more" (168 situations [38%; 95% CI, 32%-43%]). Independently associated with perceived inappropriateness of care rates both among nurses and physicians were symptom control decisions directed by physicians only (odds ratio [OR], 1.73; 95% CI, 1.17-2.56; P = .006); involvement of nurses in end-of-life decision making (OR, 0.76; 95% CI, 0.60-0.96; P = .02); good collaboration between nurses and physicians (OR, 0.72; 95% CI, 0.56-0.92; P = .009); and freedom to decide how to perform work-related tasks (OR, 0.72; 95% CI, 0.59-0.89; P = .002); while a high perceived workload was significantly associated among nurses only (OR, 1.49; 95% CI, 1.07-2.06; P = .02). Perceived inappropriateness of care was independently associated with higher intent to leave a job (OR, 1.65; 95% CI, 1.04-2.63; P = .03). In the subset of 69 ICUs for which patient data could be linked, clinicians reported received inappropriateness of care in 207 patients, representing 23% (95% CI, 20%-27%) of 883 ICU beds. Among a group of European and Israeli ICU clinicians, perceptions of inappropriate care were frequently reported and were inversely associated with factors indicating good teamwork.

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Author and article information

Contributors

D. D. Benoit:

ORCID: http://orcid.org/0000-0002-0227-5169

dominique.benoit@ugent.be

Journal

Journal ID (nlm-ta): Intensive Care Med

Journal ID (iso-abbrev): Intensive Care Med

Title: Intensive Care Medicine

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0342-4642

ISSN (Electronic): 1432-1238

Publication date (Electronic): 28 May 2018

Publication date PMC-release: 28 May 2018

Publication date (Print): 2018

Volume: 44

Issue: 7

Pages: 1039-1049

Affiliations

[1 ]ISNI 0000 0004 0626 3303, GRID grid.410566.0, Department of Intensive Care Medicine, , Ghent University Hospital, ; Corneel Heymanslaan 10, Ghent, Belgium

[2 ]ISNI 0000 0004 0512 5814, GRID grid.417271.6, Department of Intensive Care Medicine, , Vejle Hospital, ; Vejle, Denmark

[3 ]ISNI 0000 0001 0728 0170, GRID grid.10825.3e, Institute of Regional Research, , University of Southern Denmark, ; Odense C, Denmark

[4 ]ISNI 000000009445082X, GRID grid.1649.a, Department of Anaesthesiology and Intensive Care, , Sahlgrenska University Hospital, ; Gothenburg, Sweden

[5 ]ISNI 0000 0004 0391 9020, GRID grid.46699.34, King’s College Hospital, ; London, UK

[6 ]Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

[7 ]ISNI 0000 0001 2300 6614, GRID grid.413328.f, Hôpital Saint-Louis and University, ; Paris-7, Paris, France

[8 ]ISNI 0000 0000 9100 9940, GRID grid.411798.2, Department of Anesthesiology and Intensive Care, First Faculty of Medicine, , Charles University in Prague and General University Hospital in Prague, ; Prague, Czech Republic

[9 ]ISNI 0000 0000 9011 8547, GRID grid.239395.7, Department of Anesthesia, Critical Care, and Pain Medicine, , Beth Israel Deaconess Medical Center and Harvard Medical School, ; Boston, MA USA

[10 ]Service des soins intensifs et urgences oncologiques, Institut Jules Bordet, ULB, Brussels, Belgium

[11 ]SCDU Anestesia e Rianimazione, Azienda and Ospedaliero Universitaria, “Maggiore della Carità”, Novara, Italy

[12 ]ISNI 0000 0001 0942 9821, GRID grid.11804.3c, Semmelweis University Budapest, ; Budapest, Hungary

[13 ]Intensive Care Department, Hospital S.António, Porto, Portugal

[14 ]Tettnang Hospital, Tettnang, Germany

[15 ]ISNI 0000 0001 2069 7798, GRID grid.5342.0, Department of Psycho-analysis and Clinical Consulting, Faculty of Psychology and Educational Sciences, , Ghent University, ; Ghent, Belgium

[16 ]ISNI 000000040459992X, GRID grid.5645.2, Department of Intensive Care Medicine, , Erasmus MC University Medical Center Rotterdam, ; Rotterdam, The Netherlands

[17 ]ISNI 0000 0001 2069 7798, GRID grid.5342.0, Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, , Ghent University, ; Ghent, Belgium

[18 ]ISNI 0000 0004 0425 469X, GRID grid.8991.9, London School of Hygiene and Tropical Medicine, ; London, UK

[19 ]ISNI 0000 0004 0626 3303, GRID grid.410566.0, Department of Geriatric Medicine, , Ghent University Hospital, ; Ghent, Belgium

Author information

D. D. Benoit http://orcid.org/0000-0002-0227-5169

Article

Publisher ID: 5231

DOI: 10.1007/s00134-018-5231-8

PMC ID: 6061457

PubMed ID: 29808345

SO-VID: 1230a1b9-bc7b-487f-a80e-6f4f98334620

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 10 February 2018

Date accepted : 14 May 2018

Funding

Funded by: FWO

Award ID: 1800513N

Award Recipient : D. D. Benoit

Funded by: ESICM/ECCRN

Award ID: Clinical research award

Award Recipient : D. D. Benoit

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: perceived excessive care,ethical climate,decision-making,interdisciplinary collaboration,patient outcomes,treatment-limitation decisions

Data availability: