@article{01J716RT9Y6M9G66FKC9SM23BY,
  abstract     = {{The aim of this study was to assess whether coaching doctors to enhance ethical decision-making in teams improves (1) goal-oriented care operationalized via written do-not-intubate and do-not attempt cardiopulmonary resuscitation (DNI-DNACPR) orders in adult patients potentially receiving excessive treatment (PET) during their first hospital stay and (2) the quality of the ethical climate.

Methods
We carried out a stepped-wedge cluster randomized controlled trial in the medical intensive care unit (ICU) and 9 referring internal medicine departments of Ghent University Hospital between February 2022 and February 2023. Doctors and nurses in charge of hospitalized patients filled out the ethical decision-making climate questionnaire (ethical decision-making climate questionnaire, EDMCQ) before and after the study, and anonymously identified PET via an electronic alert during the entire study period. All departments were randomly assigned to a 4-month coaching. At least one month of coaching was compared to less than one month coaching and usual care. The first primary endpoint was the incidence of written DNI-DNACPR decisions. The second primary endpoint was the EDMCQ before and after the study period. Because clinicians identified less PET than required to detect a difference in written DNI-DNACPR decisions, a post-hoc analysis on the overall population was performed. To reduce type I errors, we further restricted the analysis to one of our predefined secondary endpoints (mortality up to 1 year).

Results
Of the 442 and 423 clinicians working before and after the study period, respectively 270 (61%) and 261 (61.7%) filled out the EDMCQ. Fifty of the 93 (53.7%) doctors participated in the coaching for a mean (standard deviation [SD]) of 4.36 (2.55) sessions. Of the 7254 patients, 125 (1.7%) were identified as PET, with 16 missing outcome data. Twenty-six of the PET and 624 of the overall population already had a written DNI-DNACPR decision at study entry, resulting in 83 and 6614 patients who were included in the main and post hoc analysis, respectively. The estimated incidence of written DNI-DNACPR decisions in the intervention vs. control arm was, respectively, 29.7% vs. 19.6% (odds ratio 4.24, 95% confidence interval 4.21–4.27; P < 0.001) in PET and 3.4% vs. 1.9% (1.65, 1.12–2.43; P = 0.011) in the overall study population. The estimated mortality at one year was respectively 85% vs. 83.7% (hazard ratio 2.76, 1.26–6.04; P = 0.011) and 14.5% vs. 15.1% (0.89, 0.72–1.09; P = 0.251). The mean difference in EDMCQ before and after the study period was 0.02 points (− 0.18 to 0.23; P = 0.815).

Conclusion
This study suggests that coaching doctors regarding ethical decision-making in teams safely improves goal-oriented care operationalized via written DNI-DNACPR decisions in hospitalized patients, however without concomitantly improving the quality of the ethical climate.}},
  author       = {{Benoit, Dominique and De Pauw, Aglaja and Jacobs, Celine and Moors, Ine and Offner, Fritz and Velghe, Anja and Van Den Noortgate, Nele and Depuydt, Pieter and Druwé, Patrick and Hemelsoet, Dimitri and Meurs, Alfred and Malotaux, Jiska and Van Biesen, Wim and Verbeke, Francis and Derom, Eric and Stevens, Dieter and De Pauw, Michel and Tromp, Fiona and Van Vlierberghe, Hans and Callebout, Eduard and Goethals, Katrijn and Lievrouw, An and Liu, Limin and Manesse, Frank and Vanheule, Stijn and Piers, Ruth}},
  issn         = {{0342-4642}},
  journal      = {{INTENSIVE CARE MEDICINE}},
  keywords     = {{Advance care planning,Goal-oriented care,Ethics,Interprofessional collaboration,Decision-making,End of life,Palliative care,Treatment-limitation-decisions,INTENSIVE-CARE-UNIT,LEADERSHIP ESSENTIALS,PALLIATIVE CARE,LIFE,HEALTH,DEATH,END,PHYSICIANS,PROVIDE,NURSES}},
  language     = {{eng}},
  pages        = {{1635--1646}},
  title        = {{Coaching doctors to improve ethical decision-making in adult hospitalized patients potentially receiving excessive treatment : the CODE stepped-wedge cluster randomized controlled trial}},
  url          = {{http://doi.org/10.1007/s00134-024-07588-0}},
  volume       = {{50}},
  year         = {{2024}},
}

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