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

D. D. Benoit| H. I. Jensen| J. Malmgren| V. Metaxa| A. K. Reyners| M. Darmon| K. Rusinova| D. Talmor| A. P. Meert| L. Cancelliere| L. Zubek| P. Maia| A. Michalsen| S. Vanheule| E. J. O. Kompanje| J. Decruyenaere| S. Vandenberghe| S. Vansteelandt| B. Gadeyne| B. Van den Bulcke| E. Azoulay| R. D. Piers
Original
Volume 44, Issue 7 / July , 2018

Pages 1039 - 1049

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.

Keywords

References

  1. Wunsch H, Linde-Zwirble WT, Harrison DA, Barnato AE, Rowan KM, Angus DC (2009) Use of intensive care services during terminal hospitalizations in England and the United States. Am J Respir Crit Care Med 180:875–880
    • View reference on publisher's website
    • View reference on PubMed
  2. Teno JM, Gozalo PL, Bynum JPW, Leland NE, Miller SC, Morden NE, Scupp T, Goodman DC, Mor V (2013) Change in end-of-life care for medicare beneficiaries. Site of death, place of care, and health care transtitions in 2001 2005, and 2009. JAMA 309:470–477
    • View reference on publisher's website
    • View reference on PubMed
  3. Ho TH, Barbera L, Saskin R, Lu H, Neville BA, Earle CC (2011) Trends in aggressiveness of end of life cancer care in the universal health care system of Ontario, Canada. J Clin Oncol 29:1587–1591
    • View reference on publisher's website
    • View reference on PubMed
  4. Wang CY, Calfee CS, Paul DW, Janz DR, May AK, Zhuo H, Bernard GR, Matthay MA, Ware LB, Neudoerffer Kangelaris K (2014) One-year mortality and predictors of death among hospital survivors of acute respiratory distress syndrome. Intensive Care Med 40:388–396
  5. Garland A, Olafson K, Ramsey CD, Yogendran M, Fransoo R (2014) Distinct determinants of long-term and short-term survival in critical illness. Intensive Care Med 40:1097–1105
  6. Kompanje EJ, Piers RD, Benoit DD (2013) Causes and consequences of disproportionate care in intensive care medicine. Curr Opin Crit Care 19:630–635
    • View reference on PubMed
  7. Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton CH, Curtis JR, ford DW, Osborne M, Misak C, Au DH, Azoulay E, Brody B, Fahy BG, Hall JB, Kesecioglu J, Kon AA, Lindell KO, White DB, on behalf of the American Thoracic Society ad hoc committee on Futile and Potentially Inappropriate Treatment (2015) An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 191:1318–1330
    • View reference on publisher's website
    • View reference on PubMed
  8. Piers R, Azoulay E, Ricou B, Dekeyser Ganz F, Decruyenaere J, Max A, Michalsen A, Azevedo Maia P, Owczuk R, Rubulotta F, Depuydt P, Meert AP, Reyners A, Aquilina A, Bekaert M, Van den Noorgate N, Schrauwen W, Benoit D (2011) APPROPRICUS study group of the ESICM. Perception of appropriateness of care among European and Israeli intensive care unit nurses and doctors. JAMA 306:2694–2703
    • View reference on publisher's website
    • View reference on PubMed
  9. Piers R, Azoulay E, Ricou B, Dekeyser Ganz F, Max A, Michalsen A, Azevedo Maia P, Owczuk R, Rubulotta F, Meert AP, Reyners A, Decruyenaere J, Benoit DD (2014) Inappropriate care in European ICUs. Confronting views from nurses and junior and senior physicians. Chest 146:267–275
    • View reference on publisher's website
    • View reference on PubMed
  10. Anstey MH, Adams JL, McGlynn EA (2015) Perceptions of the appropriateness of care in California adult intensive care units. Crit Care 19:51
    • View reference on publisher's website
    • View reference on PubMed
  11. Vincent JL (1999) Forgoing life support in western European intensive care units: the results of an ethical questionnaires. Crit Care Med 27:1626–1633
    • View reference on publisher's website
    • View reference on PubMed
  12. Palda VA, Bowman KW, Mclean RF, Chapman MG (2005) “Futile” care: do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses. J Crit Care 20:207–213
    • View reference on publisher's website
    • View reference on PubMed
  13. Giannini A, Consonni D (2006) Physicians’ perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting. Br J Anaesth 96:57–62
    • View reference on publisher's website
    • View reference on PubMed
  14. Vandenbulcke B, Piers R, Jenssen HI, Malmgrem J, Metaxa V, Reyners AK, Darmon M, Rusinova K, Talmor D, Meert AP, Cancellierre L, Zubek L, Maia P, Michalsen A, Decruyenaere J, Kompanje EJO, Azoulay E, Vlerick P, Van den Sompel A, Vansteelandt S, Vanheule S, Benoit DD (2018) On behalf the DISPROPRICUS study group of the Ethics Section of the ESICM. Ethical decision-making climate in the ICU: theoretical framework and validation of self-assessment tool. BMJ Qual Saf. https://doi.org/10.1136/bmjqs-2017-007390([Epub ahead of print])
  15. Meadow W, Pohlman A, Reynolds D, Rand L, Correia C, Christoph E, Hall J (2014) Power and limitations of daily prognostications of death in the medical ICU for outcomes in the following 6 months. Crit Care Med 42:2387–2392
    • View reference on publisher's website
    • View reference on PubMed
  16. Detsky ME, Harhay MO, Bayard DF, Delman AM, Buehler AE, Kent SA, Cuiffetelli IV, Cooney E, Gabler NB, Ratcliffe SJ, Mikkelsen ME, Halpern SD (2017) Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after ICU admission. JAMA 317:2187–2195
    • View reference on publisher's website
    • View reference on PubMed
  17. Singal RK, Sibbald R, Morgan B, Quinlan M, Parry N, Radford M, Martin CM (2014) A prospective determination of the incidence of perceived inappropriate care in critically ill patients. Can Respir J 21:165–170
    • View reference on publisher's website
    • View reference on PubMed
  18. Neville TH, Wiley JF, Yamamoto MC, Flitcraft M, Anderson B, Curtis JR (2015) Concordance of nurses and physicians on whether patients are receiving futile treatment. Am J Crit Care 24:403–411
    • View reference on publisher's website
    • View reference on PubMed
  19. Brislin RW (1976) Translation: application and research. Gardner Press Inc, New York
  20. Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno RP (2012) The variability of critical care bed numbers in Europe. Intensive Care Med 38:1647–1653
  21. Rabin R, de Charro F (2001) EQ-5D: a measure of health status from the EuroQol Group. Ann Med 33:337–343
    • View reference on publisher's website
    • View reference on PubMed
  22. Oeyen SG, Vandijck D, Benoit DD, Annemans L, Decruyenaere J (2010) Quality of life after intensive care: a systematic review of the literature. Crit Care Med 38:386–400
    • View reference on publisher's website
  23. Everitt BS, Landau S, Leese M, Stahl D (2011) Cluster analyis, 5th edition. Wiley. ISBN: 978-0-470-74991-3
  24. Putter H, Fiocco M, Geskus RB (2007) Tutorial in biostatistics: competing risks and multi-state models. Statist Med 26:2389–2430
    • View reference on publisher's website
  25. Rubin DB (1997) Estimating causal effects from large data sets using propensity scores. Ann Intern Med 127:757–763
    • View reference on publisher's website
    • View reference on PubMed
  26. Lighthall GK, Vazquez-Guillamet C (2015) Understanding decision making in critical care. Clin Med Res 13:156–168
    • View reference on publisher's website
    • View reference on PubMed
  27. Zollo L, Pellegrini MM, Ciappei C (2017) What sparks ethical decision making? The interplay between moral intuition and moral reasoning: lessons from the scholastic doctrine. J Bus Ethics 145:681–700
    • View reference on publisher's website
  28. Luce JM, White DB (2009) A history of ethics and law in the intensive care unit. Crit Care Clin 25:221–237
    • View reference on publisher's website
    • View reference on PubMed
  29. Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, Michell SL, Jackson VA, Block SD, Maciejewski PK, Prigerson HG (2008) Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 300:1665–1673
    • View reference on publisher's website
    • View reference on PubMed
  30. Curtis JR, Vincent JL (2010) Ethics and end-of-life care for adults in the intensive care unit. The Lancet 376:1347–1353
    • View reference on publisher's website
  31. Kimbell B, Murray SA, Macpherson S, Boyd K (2016) Embracing inherent uncertainty in advanced illness. BMJ 354:i3802
    • View reference on publisher's website
    • View reference on PubMed
  32. Dzeng E, Curtis JR (2018) Understanding ethical climate, moral distress, and burnout: a novel tool and a conceptual framework. BMJ Qual Saf:1–5. https://doi.org/10.1136/bmjqs-2018-007905 (Epub ahead of print)
  33. Hamric AB, Blackhall LJ (2007) Nurse-physician perspective on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med 35(2):422–429
    • View reference on publisher's website
    • View reference on PubMed
  34. Schwarzkopf D, Rüddel H, Thomas-Rüddel DO, Felfe J, Poidinger B, Matthäus-Krämer CT, Hartog CS, Bloos F (2017) Perceived nonbeneficial treatment of patients, burnout, and intention to leave among ICU nurses and junior and senior physicians. Crit Care Med 45:e265–e273
    • View reference on publisher's website
    • View reference on PubMed
  35. Mark NM, Rayner SG, Lee NJ, Curtis JR (2015) Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med 41:1572–1585
  36. De Angelis R, Sant M, Coleman MP, Francisci S, Baili P, Pierannunzio D, Trama A, Visser O, Brenner H, Ardanaz E, Bielska-Lasota M, Engholm G, Nennecke A, Siesling S, Berrino F, Capocaccia R, Eurocare-5 Working Groups (2014) Cancer survival in Europe 1999–2007 by country and age: results of the Eurocare-5. A population-based study. Lancet Oncol 15:23–34
    • View reference on publisher's website
    • View reference on PubMed
  37. Khandelwal N, Kross EK, Engelberg RA, Coe NB, Long AC, Curtis JR (2015) Estimating the effect of palliative care interventions and advance care planning on the ICU utilization: a systematic review. Crit Care Med 43:1102–1111
    • View reference on publisher's website
    • View reference on PubMed
  38. Puntillo KA, McAdam JL (2006) Communication between physicians and nurses as a target for improving end-of-life care in intensive care unit: challenges and opportunities for moving forward. Crit Care Med 34(Suppl.):S332–S340
    • View reference on publisher's website
    • View reference on PubMed
  39. Jensen HI, Ammentrop J, Erlandsen M, Ording H (2011) Witholding or withdrawing therapy in intensive care units: an analysis of collaboration among healthcare professionals. Intensive Care Med 37:1696–1705
  40. Aslakson RA, Curtis JR, Nelson JE (2014) The changing role of palliative care in the ICU. Crit Care Med 42:2418–2428
    • View reference on publisher's website
    • View reference on PubMed

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