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      Physician workload associated with do-not-resuscitate decision-making in intensive care units: an observational study using Cox proportional hazards analysis

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          Physicians play a substantial role in facilitating communication regarding life-supporting treatment decision-making including do-not-resuscitate (DNR) in the intensive care units (ICU). Physician-related factors including gender, personal preferences to life-supporting treatment, and specialty have been found to affect the timing and selection of life-supporting treatment decision-making. This study aimed to examine the influence of physician workload on signing a DNR order in the ICUs.


          This is retrospective observational study. The medical records of patients, admitted to the surgical ICUs for the first time between June 1, 2011 and December 31, 2013, were reviewed. We used a multivariate Cox proportional hazards model to examine the influence of the physician’s workload on his/her writing a DNR order by adjusting for multiple factors. We then used Kaplan–Meier survival curves with log-rank test to compare the time from ICU admission to DNR orders written for patients for two groups of physicians based on the average number of patients each physician cared for per day during data collection period.


          The hazard of writing a DNR order by the attending physicians who cared for more than one patient per day significantly decreased by 41% as compared to the hazard of writing a DNR order by those caring for fewer than one patient (hazard ratio = 0.59, 95% CI 0.39—0.89, P = .01). In addition, the factors associated with writing a DNR order as determined by the Cox model were non-operative, cardiac failure/insufficiency diagnosis (hazard ratio = 1.71, 95% CI 1.00—2.91, P = .05) and the Therapeutic Intervention Scoring System score (hazard ratio = 1.02, 95% CI 1.00—1.03, P = .03). Physicians who cared for more than one patient per day were less likely to write a DNR order for their patients than those who cared for in average fewer than one patient per day (log-rank chi-square = 5.72, P = .02).


          Our findings highlight the need to take multidisciplinary actions for physicians with heavy workloads. Changes in the work environmental factors along with stress management programs to improve physicians’ psychological well-being as well as the quality.

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          Most cited references 42

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          APACHE II: a severity of disease classification system.

          This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
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            Job burnout.

            Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by the three dimensions of exhaustion, cynicism, and inefficacy. The past 25 years of research has established the complexity of the construct, and places the individual stress experience within a larger organizational context of people's relation to their work. Recently, the work on burnout has expanded internationally and has led to new conceptual models. The focus on engagement, the positive antithesis of burnout, promises to yield new perspectives on interventions to alleviate burnout. The social focus of burnout, the solid research basis concerning the syndrome, and its specific ties to the work domain make a distinct and valuable contribution to people's health and well-being.
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              Use of intensive care at the end of life in the United States: an epidemiologic study.

              Despite concern over the appropriateness and quality of care provided in an intensive care unit (ICU) at the end of life, the number of Americans who receive ICU care at the end of life is unknown. We sought to describe the use of ICU care at the end of life in the United States using hospital discharge data from 1999 for six states and the National Death Index. Retrospective analysis of administrative data to calculate age-specific rates of hospitalization with and without ICU use at the end of life, to generate national estimates of end-of-life hospital and ICU use, and to characterize age-specific case mix of ICU decedents. All nonfederal hospitals in the states of Florida, Massachusetts, New Jersey, New York, Virginia, and Washington. All inpatients in nonfederal hospitals in the six states in 1999. None. We found that there were 552,157 deaths in the six states in 1999, of which 38.3% occurred in hospital and 22.4% occurred after ICU admission. Using these data to project nationwide estimates, 540,000 people die after ICU admission each year. The age-specific rate of ICU use at the end of life was highest for infants (43%), ranged from 18% to 26% among older children and adults, and fell to 14% for those >85 yrs. Average length of stay and costs were 12.9 days and $24,541 for terminal ICU hospitalizations and 8.9 days and $8,548 for non-ICU terminal hospitalizations. One in five Americans die using ICU services. The doubling of persons over the age of 65 yrs by 2030 will require a system-wide expansion in ICU care for dying patients unless the healthcare system pursues rationing, more effective advanced care planning, and augmented capacity to care for dying patients in other settings.

                Author and article information

                [1 ]ISNI 0000 0004 0546 0241, GRID grid.19188.39, Graduate Institute of Medical Education & Bioethics, , National Taiwan University College of Medicine, ; #1, Rd. Ren-Ai sec. 1, Taipei, 10051 Taiwan
                [2 ]ISNI 0000 0004 0572 7815, GRID grid.412094.a, Department of Surgery, , National Taiwan University Hospital, ; #7, Rd. Chong-Shang S, Taipei, 10002 Taiwan
                [3 ]ISNI 0000 0004 0572 7815, GRID grid.412094.a, Department of Internal Medicine, , National Taiwan University Hospital, ; #7, Rd. Chong-Shang S, Taipei, 10002 Taiwan
                [4 ]ISNI 0000 0004 0572 7815, GRID grid.412094.a, Department of Medical Education, , National Taiwan University Hospital, ; #7, Rd. Chong-Shang S, Taipei, 10002 Taiwan
                ORCID:, 886-2-23123456 886-932159686 ,
                BMC Med Ethics
                BMC Med Ethics
                BMC Medical Ethics
                BioMed Central (London )
                1 March 2019
                1 March 2019
                : 20
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted 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. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: FundRef, Ministry of Science and Technology, Taiwan;
                Award ID: 103-2511-S-002-008-MY5
                Award Recipient :
                Funded by: FundRef, National Taiwan University Hospital;
                Award ID: 106-S3553
                Award Recipient :
                Research Article
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                © The Author(s) 2019


                do-not-resuscitate, workload, life-supporting treatment, intensive care


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