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

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...

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Published in:Intensive care medicine Vol. 44; no. 7; pp. 1039 - 1049
Main Authors: Benoit, D. D., Jensen, H. I., Malmgren, J., Metaxa, V., Reyners, A. K., Darmon, M., Rusinova, K., Talmor, D., Meert, A. P., Cancelliere, L., Zubek, L., Maia, P., Michalsen, A., Vanheule, S., Kompanje, E. J. O., Decruyenaere, J., Vandenberghe, S., Vansteelandt, S., Gadeyne, B., Van den Bulcke, B., Azoulay, E., Piers, R. D.
Format: Journal Article
Language:English
Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.07.2018
Springer
Springer Nature B.V
Subjects:
Age Factors
Anestesi och intensivvård
Anesthesiology
Anesthesiology and Intensive Care
Climate
Cluster analysis
Comparative analysis
Critical Care Medicine
Death
Decision making
Emergency Medicine
End of life
Ethics
Etik
Europe
Humans
Intensive
Intensive care
Intensive Care Units
Intensive Care Units - ethics
Medical ethics
Medicine
Medicine & Public Health
Nursing
Organizational Culture
Original
Pain Medicine
Patients
Pediatrics
Pneumology/Respiratory System
Prospective Studies
Quality of Life
Unnecessary Procedures
Europe
Greece
Western Europe
United States > US
Decision-making
Perceived excessive care
Ethical climate
Interdisciplinary collaboration
Patient outcomes
Treatment-limitation decisions
ISSN:0342-4642, 1432-1238, 1432-1238
Online Access:Get full text
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Summary: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.
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ISSN:0342-4642
1432-1238
1432-1238
DOI:10.1007/s00134-018-5231-8