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

the DISPROPRICUS study group of the Ethics Section of the European Society of Intensive Care Medicine

Research output: Contribution to journalArticle

17 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)1039-1049
Number of pages11
JournalIntensive Care Medicine
Volume44
Issue number7
DOIs
StatePublished - Jul 1 2018

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Climate
Intensive Care Units
Prospective Studies
Time Perception
Observational Studies
Cluster Analysis
Decision Making
Patient Care
Nursing
Quality of Life
Therapeutics

Keywords

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

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

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. / the DISPROPRICUS study group of the Ethics Section of the European Society of Intensive Care Medicine.

In: Intensive Care Medicine, Vol. 44, No. 7, 01.07.2018, p. 1039-1049.

Research output: Contribution to journalArticle

the DISPROPRICUS study group of the Ethics Section of the European Society of Intensive Care Medicine. / 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. In: Intensive Care Medicine. 2018 ; Vol. 44, No. 7. pp. 1039-1049.
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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.",
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TY - JOUR

T1 - Outcome in patients perceived as receiving excessive care across different ethical climates

T2 - a prospective study in 68 intensive care units in Europe and the USA

AU - the DISPROPRICUS study group of the Ethics Section of the European Society of Intensive Care Medicine

AU - Benoit, D. D.

AU - Jensen, H. I.

AU - Malmgren, J.

AU - Metaxa, V.

AU - Reyners, A. K.

AU - Darmon, M.

AU - Rusinova, K.

AU - Talmor, D.

AU - Meert, A. P.

AU - Cancelliere, L.

AU - Zubek, L.

AU - Maia, P.

AU - Michalsen, A.

AU - Vanheule, S.

AU - Kompanje, E. J.O.

AU - Decruyenaere, J.

AU - Vandenberghe, S.

AU - Vansteelandt, S.

AU - Gadeyne, B.

AU - Van den Bulcke, B.

AU - Azoulay, E.

AU - Piers, R. D.

AU - Spapen, Herbert

AU - Van Malderen, Marie Claire

AU - Opdenacker, Godelieve

AU - Meyfroidt, Geert

AU - Mesotten, Dieter

AU - Wauters, Joost

AU - Van Laer, Marie

AU - Wilmer, Alexander

AU - Wauters, Joost

AU - Ceunen, Helga

AU - De Laet, Inneke E.

AU - Jans, Anita

AU - Benoit, Dominique

AU - Oeyen, Sandra

AU - Herck, Ingrid

AU - Bracke, Stephanie

AU - Clauwaert, Charlotte

AU - Meert, Anne Pascale

AU - Leclercq, Nathalie

AU - Jacques, Devriendt

AU - Philippe, Dechamps

AU - Zykova, Ivana

AU - Malaska, Jan

AU - Schmidt, Matous

AU - Satinsky, Igor

AU - Kieslichova, Eva

AU - Krizova, Jarmila

AU - Wilson, Michael

PY - 2018/7/1

Y1 - 2018/7/1

N2 - 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.

AB - 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.

KW - Decision-making

KW - Ethical climate

KW - Interdisciplinary collaboration

KW - Patient outcomes

KW - Perceived excessive care

KW - Treatment-limitation decisions

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