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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 USA

(2018) INTENSIVE CARE MEDICINE. 44(7). p.1039-1049
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Abstract
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. 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. 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. 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
Perceived excessive care, Ethical climate, Decision-making, Interdisciplinary collaboration, Patient outcomes, Treatment-limitation decisions, OF-LIFE CARE, INAPPROPRIATE CARE, DECISION-MAKING, PALLIATIVE CARE, PHYSICIANS, HEALTH, NURSES, DEATH, ICU, PERCEPTIONS

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Chicago
Benoit, Dominique, HI Jensen, J Malmgren, V Metaxa, AK Reyners, M Darmon, K Rusinova, et al. 2018. “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.” Intensive Care Medicine 44 (7): 1039–1049.
APA
Benoit, Dominique, Jensen, H., Malmgren, J., Metaxa, V., Reyners, A., Darmon, M., Rusinova, K., et al. (2018). 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. INTENSIVE CARE MEDICINE, 44(7), 1039–1049.
Vancouver
1.
Benoit D, Jensen H, Malmgren J, Metaxa V, Reyners A, Darmon M, et al. 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. INTENSIVE CARE MEDICINE. 2018;44(7):1039–49.
MLA
Benoit, Dominique, HI Jensen, J Malmgren, et al. “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.” INTENSIVE CARE MEDICINE 44.7 (2018): 1039–1049. Print.
@article{8585798,
  abstract     = {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. 
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. 
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. 
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.},
  author       = {Benoit, Dominique and Jensen, HI and Malmgren, J and Metaxa, V and Reyners, AK and Darmon, M and Rusinova, K and Talmor, D and Meert, AP and Cancelliere, L and Zubek, L and Maia, P and Michalsen, A and Vanheule, Stijn and Kompanje, EJO and Decruyenaere, Johan and Vandenberghe, Sjouke and Vansteelandt, Stijn and Gadeyne, Bram and Van den Bulcke, Bo and Azoulay, E and Piers, RD},
  issn         = {0342-4642},
  journal      = {INTENSIVE CARE MEDICINE},
  language     = {eng},
  number       = {7},
  pages        = {1039--1049},
  title        = {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},
  url          = {http://dx.doi.org/10.1007/s00134-018-5231-8},
  volume       = {44},
  year         = {2018},
}

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