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Intensive Care Med. 2018 Jul;44(7):1039-1049. doi: 10.1007/s00134-018-5231-8. Epub 2018 May 28.

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.

Author information

1
Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium. dominique.benoit@ugent.be.
2
Department of Intensive Care Medicine, Vejle Hospital, Vejle, Denmark.
3
Institute of Regional Research, University of Southern Denmark, Odense C, Denmark.
4
Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
5
King's College Hospital, London, UK.
6
Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
7
Hôpital Saint-Louis and University, Paris-7, Paris, France.
8
Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic.
9
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
Semmelweis University Budapest, Budapest, Hungary.
13
Intensive Care Department, Hospital S.António, Porto, Portugal.
14
Tettnang Hospital, Tettnang, Germany.
15
Department of Psycho-analysis and Clinical Consulting, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium.
16
Department of Intensive Care Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
17
Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
18
Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium.
19
London School of Hygiene and Tropical Medicine, London, UK.
20
Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium.

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:

Decision-making; Ethical climate; Interdisciplinary collaboration; Patient outcomes; Perceived excessive care; Treatment-limitation decisions

PMID:
29808345
PMCID:
PMC6061457
DOI:
10.1007/s00134-018-5231-8
[Indexed for MEDLINE]
Free PMC Article

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