What is appropriate care? A qualitative study into the perceptions of healthcare professionals in Flemish university hospital intensive care units

Discussing expected long-term quality of life in the ICU: effect on experiences and outcomes of patients, family, and clinicians-a randomized clinical trial

PURPOSE

To evaluate the effect of discussing personalized predictions of long-term quality of life (QoL) on patient and family experiences and outcomes, and on experiences of ICU clinicians.

METHODS

We conducted a randomized clinical trial in two Dutch hospitals, assigning adult ICU patients to receive usual care or the intervention: discussing the expected long-term QoL based on a validated prediction model, during a family meeting in the ICU. Primary outcome was patient and family experience with shared decision-making (CollaboRATE, range 0-100), evaluated < 3 days after the family meeting. Secondary outcomes included ICU professionals' experiences (Collaboration and Satisfaction about Care Decisions [CSACD] and Ethical Decision-Making Climate Questionnaire [EDMCQ]), symptoms of anxiety and depression among patients and family, and patients' QoL 3 months and 1 year post-ICU.

RESULTS

160 patients were included, of whom 81 were randomized to receive the intervention and 79 to receive usual care. No significant differences were seen in patients' and family members' experiences (median CollaboRATE score 89 [IQR 85-100] in the intervention arm vs 93 [IQR 85-100] in the usual care arm, p = 0.6). The outcomes of patients did not differ, whereas at 1 year post-ICU family members in the usual care group reported a larger increase in depression symptoms (mean 2.3 [SD 4.2] vs 0.2 [SD 3.9], p = 0.04). Regarding ICU professionals' experiences, an improvement in CSACD score was observed post-intervention (median 40 [IQR 34-45] vs 37 [IQR 32-43], p = 0.01), while no significant change in EDMCQ was found.

CONCLUSION

Incorporating personalized predictions of long-term QoL in family meetings had no measurable effect on patients' and family members' experiences. However, a positive effect on family members' symptoms of depression and ICU professionals' experienced collaboration was observed.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov: NCT05155150.

Intensivists' ethical perceptions about decisions to withhold or withdraw treatment: A clinical ethics empirical investigation

BACKGROUND

Intensive care professional societies have issued policy recommendations regarding decisions to withhold and/or withdraw treatment (Wh&Wd) that consistently classify them as ethically equivalent and ethically neutral. However, on the ground they are often perceived as "active" and morally problematic. Moreover, recent studies have highlighted personal "variability" in the way such decisions are made. Therefore, it seemed necessary to explore intensivists' different ethical perceptions about Wh&Wd decisions.

METHODS

A qualitative retrospective and multicentered study was conducted in seven intensive care units belonging to the Paris Hospital Trust (AP-HP), which involved in-depth interviews with 44 intensivists of different ages and levels of professional experience. An inductive ("grounded theory"-inspired), multidisciplinary clinical ethics approach was used that aimed at eliciting and retrieving practitioners' ethical intuitions about different Wh&Wd decisions. Interview transcripts were analyzed using a "thematic analysis" approach.

RESULTS

Practitioners' perceptions of Wh&Wd decisions vary along two continuous dimensions: active/passive and ethically problematic/unproblematic. Three groups have been identified: those who consider Wh&Wd decisions 1) as passive and unproblematic, 2) as active and problematic, and 3) as active and unproblematic. More interestingly, these groups can be differently characterized with respect to three other ethically relevant considerations: the role of consensus during the collegial decision-making procedure, the difference between withholding and withdrawing decisions, and the definition of one's own overarching professional goal.

CONCLUSION

The study results allow for recognition of intensivists' moral distress about Wh&Wd decisions and open new perspectives to deal with their deep-rooted variability, most notably by working on the rationale and format of the collegial decision-making procedure.

Coaching doctors to improve ethical decision-making in adult hospitalized patients potentially receiving excessive treatment. The CODE stepped-wedge cluster randomized controlled trial

PURPOSE

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.

An Evolutionary Concept Analysis of the "Fighter" in the Intensive Care Unit

The purpose of this article was to analyze the concept of "the fighter in the intensive care unit (ICU)" per the scientific literature and the impact this mentality has on care administered in the ICU. A literature review and a concept analysis based on Rodger's evolutionary method were performed to identify surrogate terms, antecedents, attributes, and consequences pertaining to the "fighter" in the ICU. Thirteen articles with a focus on "the fighter" were included in this analysis. There is a strong desire to remain optimistic and maintain high spirits as a coping mechanism in the face of extreme prognostic uncertainty. Themes that emerged from the literature were the need to find inner strength and persist in the face of adversity. The concept of "the fighter in the ICU" can serve as either adaptive or maladaptive coping, depending on the larger clinical picture. Patient experiences in the ICU are fraught with physical and psychological distress. How the patient and family unit cope during this anxiety-provoking time is based on the individual. Maintaining optimism and identifying as a fighter can be healthy ways to adapt to the circumstances. This concept analysis highlights the importance of holistic care and instilling hope particularly as patients may be nearing the end of life.

What drives the green development behavior of local governments? A perspective of grounded theory

Although the elements that lead local governments to adopt sustainable development behaviors have been examined, the underlying processes that local governments adopt to accomplish green development behavior (GDB) lack systematic theoretical analysis. This study aims to investigate the determinants influencing local governments' implementation of GDB from the organizational internal and external perspectives. This study employed grounded theory to analyze the data and develop an influencing factor model of local government green development behavior (GDB-LG) after interviewing 53 Chinese local officials. Additionally, through integrating process organization research with new institutional theory, the mechanism that explains how these elements influence GDB was investigated. The results of the study demonstrate that the influencing factors model could give municipal governments clear guidance when creating sensible green development policies, further enhancing the efficacy of GDB.

Recasting the gold standard - part I of II: delineating healthcare options across a continuum of care

AIM

This is the first part of a two-part series on spectrum of care that encourages practitioners to embrace a non-binary approach to healthcare delivery. When care is not framed as all-or-none, either/or or best versus lesser, the provider and client can agree to diagnostic and/or treatment plans that individualize the practice of veterinary medicine. Care is tailored to the patient along a continuum of acceptable options. Care may also be intentionally incremental, with plans to reassess the patient and revise case management as needed.

RELEVANCE

Acknowledgment and ultimately acceptance that patient care journeys can be distinct, yet equitably appropriate, offers providers the flexibility to adapt case management competently and confidently to the patient based upon contextualized circumstances including client needs, wants and expectations for healthcare outcomes. Thinking outside the box to recast the historic gold standard with a continuum of care strategically offers feline practitioners a means by which they can overcome barriers to healthcare delivery.

SERIES OUTLINE

This first article introduces spectrum of care as an appropriate approach to case management and broadens its definition beyond cost of care. Part II explores communication strategies that enhance veterinary professionals' delivery of spectrum of care through open exchange of relationship-centered dialogue.