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Azoulay É, Kentish-Barnes N, Boulanger C, Mistraletti G, van Mol M, Heras-La Calle G, Estenssoro E, van Heerden PV, Delgado MCM, Perner A, Arabi YM, Myatra SN, Laake JH, De Waele JJ, Darmon M, Cecconi M. Family centeredness of care: a cross-sectional study in intensive care units part of the European society of intensive care medicine. Ann Intensive Care 2024; 14:77. [PMID: 38771395 PMCID: PMC11109056 DOI: 10.1186/s13613-024-01307-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 05/05/2024] [Indexed: 05/22/2024] Open
Abstract
PURPOSE To identify key components and variations in family-centered care practices. METHODS A cross-sectional study, conducted across ESICM members. Participating ICUs completed a questionnaire covering general ICU characteristics, visitation policies, team-family interactions, and end-of-life decision-making. The primary outcome, self-rated family-centeredness, was assessed using a visual analog scale. Additionally, respondents completed the Maslach Burnout Inventory and the Ethical Decision Making Climate Questionnaire to capture burnout dimensions and assess the ethical decision-making climate. RESULTS The response rate was 53% (respondents from 359/683 invited ICUs who actually open the email); participating healthcare professionals (HCPs) were from Europe (62%), Asia (9%), South America (6%), North America (5%), Middle East (4%), and Australia/New Zealand (4%). The importance of family-centeredness was ranked high, median 7 (IQR 6-8) of 10 on VAS. Significant differences were observed across quartiles of family centeredness, including in visitation policies availability of a waiting rooms, family rooms, family information leaflet, visiting hours, night visits, sleep in the ICU, and in team-family interactions, including daily information, routine day-3 conference, and willingness to empower nurses and relatives. Higher family centeredness correlated with family involvement in rounds, participation in patient care and end-of-life practices. Burnout symptoms (41% of respondents) were negatively associated with family-centeredness. Ethical climate and willingness to empower nurses were independent predictors of family centeredness. CONCLUSIONS This study emphasizes the need to prioritize healthcare providers' mental health for enhanced family-centered care. Further research is warranted to assess the impact of improving the ethical climate on family-centeredness.
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Affiliation(s)
- Élie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris-Cité University, 1 avenue Claude Vellefaux, Paris, 75010, France.
| | - Nancy Kentish-Barnes
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris-Cité University, 1 avenue Claude Vellefaux, Paris, 75010, France
| | - Carole Boulanger
- Royal Devon University NHS Foundation Trust, Barrack Road, Exeter, UK
| | - Giovanni Mistraletti
- Dipartimento di Fisiopatologia medico-chirurgica e dei trapianti. A.S.S.T. Ovest Milanese, Università degli Studi di Milano, Ospedale Civile di Legnano, Legnano, MI, Italy
| | | | - Gabriel Heras-La Calle
- International Research Project for the Humanisation of Intensive Care Units, Proyecto HU-CI, Madrid, Spain
- Humanizing Healthcare Foundation. Intensive Care Unit, Hospital Universitario de Jaén, Jaén, Spain
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos General San Martín, La Plata, Buenos Aires, Argentina
| | - Peter Vernon van Heerden
- Department of Anesthesiology, Critical Care and Pain medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Maria-Cruz Martin Delgado
- Department Intensive Care Medicine Hospital 12 de Octubre, Madrid, Spain
- Research Institute "Hospital 12 de Octubre (imas12)", Universidad Complutense de Madrid, Madrid, Spain
| | - Anders Perner
- Department of Intensive Care, Department of Clinical Medicine, Copenhagen University Hospital - Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Yaseen M Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health - Affairs, and College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute Mumbai, Mumbai, India
| | - Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Division of Critical Care and Emergencies, Rikshopitalet Medical Centre, Oslo University Hospital, Oslo, Norway
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Gent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Michael Darmon
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris-Cité University, 1 avenue Claude Vellefaux, Paris, 75010, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Via Levi Montalcini, Pieve Emanuele, MI, Italy
- 2IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
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Aloy-Duch A, Santiñà Vila M, Ramos-d'Angelo F, Alonso Calo L, Llaneza-Velasco ME, Fortuny-Organs B, Apezetxea-Celaya A. [Synthetic indicator of compliance with standards for Quality Units of health centers and multicenter prospective pilot study]. J Healthc Qual Res 2024:S2603-6479(24)00024-1. [PMID: 38594160 DOI: 10.1016/j.jhqr.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 03/04/2024] [Accepted: 03/15/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND OBJECTIVE In Spain, Quality Units play a key and unique role in advising healthcare centers on the methodology of healthcare quality. The objectives of the study were to develop computer algorithms to obtain a synthetic indicator of standard compliance for Quality Units and to pilot its functioning in these units. MATERIALS AND METHODS The Excel program was used to establish evaluation algorithms, and quantitatively interrelate and weight various categories of standards, as a computer evaluation tool, to build a continuous improvement cycle system, and offer a global synthetic indicator of compliance. The tool was tested in a prospective multicenter pilot study, in which coordinators of Quality Units from different health centers and care settings participated, to evaluate the usefulness of the tool and compliance with the standards, in addition to analyzing the content validity of each standard. RESULTS The formulas for the structured computer algorithms were developed, consecutively, in a «PLAN-DO-CHECK-ACT» improvement cycle for the 9 categories of standards, resulting in a single synthetic indicator of compliance. Twenty-one Quality Units participated in the piloting. The overall average compliance rate for the synthetic indicator was 55.63% with differences between centers (P=.002) and between categories (P<.0001), but not by autonomous communities (P=.86) or by areas (P=.97). Content validity was ensured through the variable of «understanding» of the standards (P<.001), and through their «justification» with documentary evidence (P<.001). CONCLUSIONS The computer tool with the synthetic indicator have allowed for the evaluation of standard compliance in Quality Units of healthcare centers.
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Affiliation(s)
- A Aloy-Duch
- Director de Calidad y Planificación, Hospital General de Granollers, Granollers, Barcelona, España.
| | - M Santiñà Vila
- Sociedad Española de Calidad Asistencial (Past President), Investigador del Institut de Recerca Biomèdica August Pi i Sunyer, Barcelona, España
| | - F Ramos-d'Angelo
- Coordinador de Calidad, Hospital Royo Villanova, Zaragoza, España
| | - L Alonso Calo
- Responsable de Calidad y Seguridad del Paciente, Hospital Universitario Central de Asturias, Área Sanitaria IV SESPA, Oviedo, España
| | - M E Llaneza-Velasco
- Servicio de Microbiología, Hospital Universitario Central de Asturias, Presidenta de la Asociación Calidad Asistencial del Principado de Asturias - PASQAL, Oviedo, España
| | - B Fortuny-Organs
- Unidad de Calidad, Hospital Marina Salud, Denia, Alicante, España
| | - A Apezetxea-Celaya
- Unidad de Calidad, Organización Sanitaria Integrada Bilbao-Basurto, Osakidetza - Servicio Vasco de Salud, Bilbao, España
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Dzeng E, Batten JN, Dohan D, Blythe J, Ritchie CS, Curtis JR. Hospital Culture and Intensity of End-of-Life Care at 3 Academic Medical Centers. JAMA Intern Med 2023; 183:839-848. [PMID: 37399038 PMCID: PMC10318547 DOI: 10.1001/jamainternmed.2023.2450] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/22/2023] [Indexed: 07/04/2023]
Abstract
Importance There is substantial institutional variability in the intensity of end-of-life care that is not explained by patient preferences. Hospital culture and institutional structures (eg, policies, practices, protocols, resources) might contribute to potentially nonbeneficial high-intensity life-sustaining treatments near the end of life. Objective To understand the role of hospital culture in the everyday dynamics of high-intensity end-of-life care. Design, Setting, and Participants This comparative ethnographic study was conducted at 3 academic hospitals in California and Washington that differed in end-of-life care intensity based on measures in the Dartmouth Atlas and included hospital-based clinicians, administrators, and leaders. Data were deductively and inductively analyzed using thematic analysis through an iterative coding process. Main Outcome and Measure Institution-specific policies, practices, protocols, and resources and their role in the everyday dynamics of potentially nonbeneficial, high-intensity life-sustaining treatments. Results A total of 113 semistructured, in-depth interviews (66 women [58.4%]; 23 [20.4%] Asian, 1 [0.9%] Black, 5 [4.4%] Hispanic, 7 [6.2%] multiracial, and 70 [61.9%] White individuals) were conducted with inpatient-based clinicians and administrators between December 2018 and June 2022. Respondents at all hospitals described default tendencies to provide high-intensity treatments that they believed were universal in US hospitals. They also reported that proactive, concerted efforts among multiple care teams were required to deescalate high-intensity treatments. Efforts to deescalate were vulnerable to being undermined at multiple points during a patient's care trajectory by any individual or entity. Respondents described institution-specific policies, practices, protocols, and resources that engendered broadly held understandings of the importance of deescalating nonbeneficial life-sustaining treatments. Respondents at different hospitals reported different policies and practices that encouraged or discouraged deescalation. They described how these institutional structures contributed to the culture and everyday dynamics of end-of-life care at their institution. Conclusions and Relevance In this qualitative study, clinicians, administrators, and leaders at the hospitals studied reported that they work in a hospital culture in which high-intensity end-of-life care constitutes a default trajectory. Institutional structures and hospital cultures shape the everyday dynamics by which clinicians may deescalate end-of-life patients from this trajectory. Individual behaviors or interactions may fail to mitigate potentially nonbeneficial high-intensity life-sustaining treatments if extant hospital culture or a lack of supportive policies and practices undermine individual efforts. Hospital cultures need to be considered when developing policies and interventions to decrease potentially nonbeneficial, high-intensity life-sustaining treatments.
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Affiliation(s)
- Elizabeth Dzeng
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Cicely Saunders institute, King’s College London, London, England
| | - Jason N. Batten
- Department of Anesthesia, Perioperative, and Pain Medicine, Stanford University, Stanford, California
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, California
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Jacob Blythe
- Department of Radiology, Massachusetts General Hospital, Boston
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute Center for Aging and Serious Illness, Department of Medicine, Massachusetts General Hospital, Boston
| | - J. Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
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van Zuylen ML, de Snoo-Trimp JC, Metselaar S, Dongelmans DA, Molewijk B. Moral distress and positive experiences of ICU staff during the COVID-19 pandemic: lessons learned. BMC Med Ethics 2023; 24:40. [PMID: 37291555 PMCID: PMC10249541 DOI: 10.1186/s12910-023-00919-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. METHODS A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. RESULTS All 178 respondents (response rate: 25-32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to 'team cooperation', 'team solidarity' and 'work ethic'. Lessons learned were mostly related to 'quality of care' and 'professional qualities'. CONCLUSIONS Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals' dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. TRIAL REGISTRATION The trial was registered on The Netherlands Trial Register, number NL9177.
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Affiliation(s)
- Mark L. van Zuylen
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Janine C. de Snoo-Trimp
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, De Boelelaan 1089a, Amsterdam, 1081 HV The Netherlands
| | - Suzanne Metselaar
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, De Boelelaan 1089a, Amsterdam, 1081 HV The Netherlands
| | - Dave A. Dongelmans
- Department of Intensive Care, Amsterdam, UMC, University of Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, De Boelelaan 1089a, Amsterdam, 1081 HV The Netherlands
- Center of Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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5
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Hlaing PH, Hasswan A, Salmanpour V, Shorbagi S, AlMahmoud T, Jirjees FJ, Kawas SA, Guraya SY, Sulaiman N. Health professions students' approaches towards practice-driven ethical dilemmas; a case-based qualitative study. BMC MEDICAL EDUCATION 2023; 23:307. [PMID: 37131157 PMCID: PMC10152413 DOI: 10.1186/s12909-023-04089-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 02/09/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND In healthcare practice, ethical challenges are inevitable and their optimal handling may potentialy improve patient care. Ethical development in medical education is critical for the transition from a medical and health sciences student to an ethical healthcare practitioner. Understanding the health professions students' approaches towards practice-driven ethical dilemmas could harness i the effective ethical development in their medical education. This study attempts to identify the health professions students' approaches towards practice-driven ethical dilemmas. METHODS An inductive qualitative evaluation was conducted on six recorded videos of health professions students' case-based online group discussions, followed by a one-hour online ethics workshop. The online ethics workshop was organized with students from the College of Medicine, College of Dental Medicine and College of Pharmacy at the University of Sharjah, and the College of Medicine at the United Arab Emirates University. . The recorded videos were transcribed verbatim and imported to the qualitative data analysis software of MAXQDA 2022. Data were analyzed applying four stages of review, reflect, reduce and retrieve and two different coders triangulated the findings. RESULTS Six themes emerged from the qualitative analysis of the health professions students' approaches to the practice-based ethical dilemmas; (1) emotions, (2) personal experiences, (3) law and legal system, (4) professional background, (5) knowledge of medical research and (6) inter-professional education. In addition, during the case-based group discussions in the ethics workshop, students efficiently applied the relevant ethical principles of autonomy, beneficence, non-maleficence and justice in their reasoning process to reach an ethical decision. CONCLUSION The findings of this study explained how health professions students resolve ethical dilemmas in their ethical reasoning process. This work sheds light on ethical development in medical education by gaining students' perspectives in dealing with complex clinical scenarios. The findings from this qualitative evaluation will aid academic medical institutions in developing medical and research-based ethics curriculum to transform students to ethical leaders.
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Affiliation(s)
- Phyu Hnin Hlaing
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Ahmed Hasswan
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Vida Salmanpour
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Sarra Shorbagi
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Tahra AlMahmoud
- College of Medicine and Health Science, United Arab Emirates University, Sharjah, United Arab Emirates
| | | | - Sausan Al Kawas
- College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | | | - Nabil Sulaiman
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.
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Porter LL, Simons KS, van der Hoeven H, van den Boogaard M, Zegers M. Different perspectives of ethical climate and collaboration between ICU physicians and nurses. Intensive Care Med 2023; 49:600-601. [PMID: 37029791 PMCID: PMC10082341 DOI: 10.1007/s00134-023-07051-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Lucy L Porter
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands.
- Department of Intensive Care, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
| | - Koen S Simons
- Department of Intensive Care, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Hans van der Hoeven
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Zegers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Benoit DD, Vanheule S, Manesse F, Anseel F, De Soete G, Goethals K, Lievrouw A, Vansteelandt S, De Haan E, Piers R. Coaching doctors to improve ethical decision-making in adult hospitalised patients potentially receiving excessive treatment: Study protocol for a stepped wedge cluster randomised controlled trial. PLoS One 2023; 18:e0281447. [PMID: 36943825 PMCID: PMC10030010 DOI: 10.1371/journal.pone.0281447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/18/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Fast medical progress poses a significant challenge to doctors, who are asked to find the right balance between life-prolonging and palliative care. Literature indicates room for enhancing openness to discuss ethical sensitive issues within and between teams, and improving decision-making for benefit of the patient at end-of-life. METHODS Stepped wedge cluster randomized trial design, run across 10 different departments of the Ghent University Hospital between January 2022 and January 2023. Dutch speaking adult patients and one of their relatives will be included for data collection. All 10 departments were randomly assigned to start a 4-month coaching period. Junior and senior doctors will be coached through observation and debrief by a first coach of the interdisciplinary meetings and individual coaching by the second coach to enhance self-reflection and empowering leadership and managing group dynamics with regard to ethical decision-making. Nurses, junior doctors and senior doctors anonymously report perceptions of excessive treatment via the electronic patient file. Once a patient is identified by two or more different clinicians, an email is sent to the second coach and the doctor in charge of the patient. All nurses, junior and senior doctors will be invited to fill out the ethical decision making climate questionnaire at the start and end of the 12-months study period. Primary endpoints are (1) incidence of written do-not-intubate and resuscitate orders in patients potentially receiving excessive treatment and (2) quality of ethical decision-making climate. Secondary endpoints are patient and family well-being and reports on quality of care and communication; and clinician well-being. Tertiairy endpoints are quantitative and qualitative data of doctor leadership quality. DISCUSSION This is the first randomized control trial exploring the effects of coaching doctors in self-reflection and empowering leadership, and in the management of team dynamics, with regard to ethical decision-making about patients potentially receiving excessive treatment.
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Affiliation(s)
- Dominique D. Benoit
- Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
- Intensive Care Medicine, University Hospital Ghent, Gent, Belgium
| | - Stijn Vanheule
- Ghent University Faculty of Psychology and Educational Sciences, Gent, Belgium
| | - Frank Manesse
- Independent, Conversio, Gent, Belgium
- Kets de Vries Institute, London, United Kingdom
| | - Frederik Anseel
- Ghent University Faculty of Psychology and Educational Sciences, Gent, Belgium
| | - Geert De Soete
- Ghent University Faculty of Psychology and Educational Sciences, Gent, Belgium
| | | | - An Lievrouw
- Intensive Care Medicine, University Hospital Ghent, Gent, Belgium
- Ghent University Hospital Cancer Centre, Gent, Belgium
| | - Stijn Vansteelandt
- Faculty of Applied Mathematics, Computer Sciences and Statistics, Ghent University Faculty of Sciences, Gent, Belgium
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Erik De Haan
- Hult International Business School Ashridge Centre for Coaching, Berkhamsted, United Kingdom
- VU Amsterdam School of Business and Economics, Amsterdam, The Netherlands
| | - Ruth Piers
- Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
- Ghent University Hospital Geriatrics, Gent, Belgium
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Huwel L, Van Eessen J, Gunst J, Malbrain ML, Bosschem V, Vanacker T, Verhaeghe S, Benoit DD. What is appropriate care? A qualitative study into the perceptions of healthcare professionals in Flemish university hospital intensive care units. Heliyon 2023; 9:e13471. [PMID: 36816284 PMCID: PMC9929305 DOI: 10.1016/j.heliyon.2023.e13471] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Aim This study examines when healthcare professionals consider intensive care as appropriate care. Background Despite attempts to conceptualize appropriate care in prior research, there is a lack of insight into its meaning and implementation in practice. This is an important issue because healthcare professionals as well as patients and relatives report inappropriate care in the intensive care unit (ICU) on a regular basis. Methods A qualitative study was designed, based on principles of grounded theory. Seventeen semi-structured interviews were conducted with nurses, doctors and doctors in training from three Flemish university hospitals. Analyses followed the Quagol method; insights were gained by means of the constant comparative method. Results Healthcare professionals described appropriate care as socially sustainable care, high-quality care, patient-oriented care, dignified care and meaningful care. They considered it important that care is not only proportional to the expected survival and quality of life of the patient and in line with the patient's or relatives' wishes, but also that the pursuit of the care goals is proportional to the patient's suffering.Although healthcare professionals indicated the same elements of appropriate care, they were defined and interpreted in individual and therefore different ways. This diversity lies at the basis of fields of tension and frustrations among healthcare professionals. Conclusion Appropriate care is defined and interpreted in individual and therefore different ways. In order to decide which type of care is appropriate for a specific patient, a process of open and constructive communication in a team is recommended.
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Affiliation(s)
- Lore Huwel
- Ghent University Hospital, Department of Intensive Care Medicine, Corneel Heymanslaan 10, 9000 Ghent, Belgium
- Corresponding author.
| | - Joke Van Eessen
- Ghent University Hospital, Department of Intensive Care Medicine, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Jan Gunst
- Leuven University Hospital, Department of Intensive Care Medicine; Campus Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
- KU Leuven, Department of Cellular and Molecular Medicine, Laboratory of Intensive Care Medicine, Onderwijs & Navorsing 1 (O&N1) Building of Campus Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
| | - Manu L.N.G. Malbrain
- Brussels University Hospital, Department of Intensive Care; Brussels Health Campus, Laarbeeklaan 101, 1090 Jette, Belgium
- International Fluid Academy, iMERiT vzw, Dreef 3, 3360 Lovenjoel, Belgium
| | - Veerle Bosschem
- Ghent University Hospital, Department of Intensive Care Medicine, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Tom Vanacker
- Ghent University Hospital, Department of Intensive Care Medicine, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Sofie Verhaeghe
- Ghent University, Centre for Nursing and Midwifery, Department of Public Health and Primary Care, UZ Gent, 5K3 (entrance 42), Corneel Heymanslaan 10, 9000 Gent, Belgium
- VIVES University College Leuven, Department of Nursing, VIVES Roeselare, Wilgenstraat 32, 8800 Roeselare, Belgium
- Hasselt University, Faculty of Medicine and Life Science; Agoralaan, 3590 Diepenbeek, Belgium
| | - Dominique D. Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
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Latour JM, Kentish-Barnes N, Jacques T, Wysocki M, Azoulay E, Metaxa V. Improving the intensive care experience from the perspectives of different stakeholders. Crit Care 2022; 26:218. [PMID: 35850700 PMCID: PMC9289931 DOI: 10.1186/s13054-022-04094-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 01/02/2023] Open
Abstract
The intensive care unit (ICU) is a complex environment where patients, family members and healthcare professionals have their own personal experiences. Improving ICU experiences necessitates the involvement of all stakeholders. This holistic approach will invariably improve the care of ICU survivors, increase family satisfaction and staff wellbeing, and contribute to dignified end-of-life care. Inclusive and transparent participation of the industry can be a significant addition to develop tools and strategies for delivering this holistic care. We present a report, which follows a round table on ICU experience at the annual congress of the European Society of Intensive Care Medicine. The aim is to discuss the current evidence on patient, family and healthcare professional experience in ICU is provided, together with the panel’s suggestions on potential improvements. Combined with industry, the perspectives of all stakeholders suggest that ongoing improvement of ICU experience is warranted.
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Secunda KE, Kruser JM. Patient-Centered and Family-Centered Care in the Intensive Care Unit. Clin Chest Med 2022; 43:539-550. [PMID: 36116821 PMCID: PMC9885766 DOI: 10.1016/j.ccm.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Patient-centered and family-centered care (PFCC) is widely recognized as integral to high-quality health-care delivery. The highly technical nature of critical care puts patients and families at risk of dehumanization and renders the delivery of PFCC in the intensive care unit (ICU) challenging. In this article, we discuss the history and terminology of PFCC, describe interventions to promote PFCC, highlight limitations to the current model, and offer future directions to optimize PFCC in the ICU.
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Affiliation(s)
- Katharine E Secunda
- Department of Medicine, Division of Pulmonary and Critical Care, University of Pennsylvania
| | - Jacqueline M Kruser
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
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11
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Gustavsson ME, Juth N, Arnberg FK, von Schreeb J. Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders. Confl Health 2022; 16:24. [PMID: 35527276 PMCID: PMC9079207 DOI: 10.1186/s13031-022-00456-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 04/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Disasters are chaotic events with healthcare needs that overwhelm available capacities. Disaster healthcare responders must make difficult and swift choices, e.g., regarding who and what to prioritize. Responders dealing with such challenging choices are exposed to moral stress that might develop into moral distress and affect their wellbeing. We aimed to explore how deployed international disaster healthcare responders perceive, manage and are affected by moral challenges. Methods Focus groups discussions were conducted with 12 participants which were Swedish nurses and physicians with international disaster healthcare experience from three agencies. The transcribed discussions were analyzed using content analysis. Results We identified five interlinked themes on what influenced perceptions of moral challenges; and how these challenges were managed and affected responders’ wellbeing during and after the response. The themes were: “type of difficult situation”, “managing difficult situations”, “tools and support”, “engagement as a protective factor”, and “work environment stressors as a risk factor. Moral challenges were described as inevitable and predominant when working in disaster settings. The responders felt that their wellbeing was negatively affected depending on the type and length of their stay and further; severity, repetitiveness of encounters, and duration of the morally challenging situations. Responders had to be creative and constructive in resolving and finding their own support in such situations, as formal support was often either lacking or not considered appropriate. Conclusion The participating disaster healthcare responders were self-taught to cope with both moral challenges and moral distress. We found that the difficult experiences also had perceived positive effects such as personal and professional growth and a changed worldview, although at a personal cost. Support considered useful was foremost collegial support, while psychosocial support after deployment was considered useful provided that this person had knowledge of the working conditions and/or similar experiences. Our findings may be used to inform organizations’ support structures for responders before, during and after deployment. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-022-00456-y.
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12
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Global Comparison of Communication of End-of-Life Decisions in the ICU. Chest 2022; 162:1074-1085. [DOI: 10.1016/j.chest.2022.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 03/22/2022] [Accepted: 05/04/2022] [Indexed: 11/20/2022] Open
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13
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Silverman H, Wilson T, Tisherman S, Kheirbek R, Mukherjee T, Tabatabai A, McQuillan K, Hausladen R, Davis-Gilbert M, Cho E, Bouchard K, Dove S, Landon J, Zimmer M. Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center. BMC Med Ethics 2022; 23:45. [PMID: 35439950 PMCID: PMC9017406 DOI: 10.1186/s12910-022-00775-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Commentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units (ICUs). Our aim was twofold: (1) to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and (2) determine the association between the ethical climate, moral distress, and intention to leave. METHODS We performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 nurses and physicians in a large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire (EDMCQ) and the Measure of Moral Distress for Healthcare Professionals (MMD-HP) tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave. RESULTS Nurses perceived the ethical climate for decision-making as less favorable than physicians (p < 0.05). They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/Pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units (3.54 ± 0.66 vs. 3.43 ± 0.81 vs. 3.30 ± 0.69; respectively; both p ≤ 0.05) and also demonstrated lower moral distress scores (both p < 0.05) and lower "intention to leave" scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated (r = -0.58, p < 0.001); moral distress and "intention to leave" was positively correlated (r = 0.52, p < 0.001); and ethical climate and "intention to leave" were negatively correlated (r = -0.50, p < 0.001). CONCLUSIONS Significant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care.
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Affiliation(s)
- Henry Silverman
- University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
| | - Tracey Wilson
- University of Maryland Medical Center, Baltimore, USA
| | - Samuel Tisherman
- University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Raya Kheirbek
- University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | | | - Ali Tabatabai
- University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | | | | | | | - Eunsung Cho
- University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | | | - Samantha Dove
- University of Maryland Medical Center, Baltimore, USA
| | - Julie Landon
- University of Maryland Medical Center, Baltimore, USA
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Mentzelopoulos SD, Chen S, Nates JL, Kruser JM, Hartog C, Michalsen A, Efstathiou N, Joynt GM, Lobo S, Avidan A, Sprung CL. Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill. Crit Care 2022; 26:106. [PMID: 35418103 PMCID: PMC9009016 DOI: 10.1186/s13054-022-03971-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions.
Methods The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset. Results In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008]. Conclusions Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03971-9.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675, Athens, Greece.
| | - Su Chen
- D2, K Lab, Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care Medicine, The University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Christiane Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité University Medicine Berlin, Berlin, Germany.,Klinik Bavaria, Kreischa, Germany
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine, and Pain Therapy, Konstanz Hospital, Konstanz, Germany
| | - Nikolaos Efstathiou
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Suzana Lobo
- Critical Care Division - Faculty of Medicine São José do Rio Preto, São Paulo, Brazil
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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15
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Plagg B, Piccoliori G, Engl A, Wiedermann CJ, Mahlknecht A, Barbieri V, Ausserhofer D, Koler P, Tauber S, Lechner M, Lorenz WA, Conca A, Eisendle K. Disaster Response in Italian Nursing Homes: A Qualitative Study during the COVID-19 Pandemic. Geriatrics (Basel) 2022; 7:geriatrics7020032. [PMID: 35314604 PMCID: PMC8938780 DOI: 10.3390/geriatrics7020032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/22/2022] Open
Abstract
Nursing homes (NHs) have been among the care settings most affected by both the virus itself and collateral damage through infection protection and control measures (IPC). However, there is a paucity of research regarding disaster response and preparedness of these institutions. The present study aimed to analyze disaster response and management and to develop prospective strategies for disaster management in NHs. A qualitative survey including (i) residents, (ii) nursing staff, (iii) relatives of residents, and (iv) NHs’ medical leads was performed. Data were collected by 45 in-depth interviews. Our results indicate that the shift from resident-centered care towards collective-protective approaches led through the suspending of established care principles to an emergency vacuum: implementable strategies were lacking and the subsequent development of temporary, immediate, and mostly suboptimal solutions by unprepared staff led to manifold organizational, medical, and ethical conflicts against the background of unclear legislation, changing protocols, and fear of legal consequences. IPC measures had long-lasting effects on the health and wellbeing of residents, relatives, and professionals. Without disaster preparedness protocols and support in decision-making during disasters, professionals in NHs are hardly able to cope with emergency situations.
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Affiliation(s)
- Barbara Plagg
- Institute of General Practice and Public Health, Provincial College for Health Professions Claudiana, 39100 Bolzano, Italy; (G.P.); (A.E.); (C.J.W.); (A.M.); (V.B.); (D.A.); (K.E.)
- Faculty of Education, Free University of Bolzano Bozen, 39100 Bolzano, Italy
- Correspondence: ; Tel.: +39-333-300-6080
| | - Giuliano Piccoliori
- Institute of General Practice and Public Health, Provincial College for Health Professions Claudiana, 39100 Bolzano, Italy; (G.P.); (A.E.); (C.J.W.); (A.M.); (V.B.); (D.A.); (K.E.)
| | - Adolf Engl
- Institute of General Practice and Public Health, Provincial College for Health Professions Claudiana, 39100 Bolzano, Italy; (G.P.); (A.E.); (C.J.W.); (A.M.); (V.B.); (D.A.); (K.E.)
| | - Christian J. Wiedermann
- Institute of General Practice and Public Health, Provincial College for Health Professions Claudiana, 39100 Bolzano, Italy; (G.P.); (A.E.); (C.J.W.); (A.M.); (V.B.); (D.A.); (K.E.)
- Department of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, 6060 Hall in Tyrol, Austria
| | - Angelika Mahlknecht
- Institute of General Practice and Public Health, Provincial College for Health Professions Claudiana, 39100 Bolzano, Italy; (G.P.); (A.E.); (C.J.W.); (A.M.); (V.B.); (D.A.); (K.E.)
| | - Verena Barbieri
- Institute of General Practice and Public Health, Provincial College for Health Professions Claudiana, 39100 Bolzano, Italy; (G.P.); (A.E.); (C.J.W.); (A.M.); (V.B.); (D.A.); (K.E.)
| | - Dietmar Ausserhofer
- Institute of General Practice and Public Health, Provincial College for Health Professions Claudiana, 39100 Bolzano, Italy; (G.P.); (A.E.); (C.J.W.); (A.M.); (V.B.); (D.A.); (K.E.)
| | - Peter Koler
- Nonprofit Organization Forum Prevention, 39100 Bolzano, Italy; (P.K.); (S.T.); (M.L.)
| | - Sara Tauber
- Nonprofit Organization Forum Prevention, 39100 Bolzano, Italy; (P.K.); (S.T.); (M.L.)
| | - Manuela Lechner
- Nonprofit Organization Forum Prevention, 39100 Bolzano, Italy; (P.K.); (S.T.); (M.L.)
| | - Walter A. Lorenz
- Department of Applied Social Sciences, Faculty of Humanities, Charles University, 182 00 Prague, Czech Republic;
| | - Andreas Conca
- Department of Psychiatry, Bolzano Central Hospital, 39100 Bolzano, Italy;
| | - Klaus Eisendle
- Institute of General Practice and Public Health, Provincial College for Health Professions Claudiana, 39100 Bolzano, Italy; (G.P.); (A.E.); (C.J.W.); (A.M.); (V.B.); (D.A.); (K.E.)
- Academic Teaching Department of Dermatology, Venereology and Allergology, Bolzano Central Hospital, 39100 Bolzano, Italy
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Aslakson RA, Cox CE, Baggs JG, Curtis JR. Palliative and End-of-Life Care: Prioritizing Compassion Within the ICU and Beyond. Crit Care Med 2021; 49:1626-1637. [PMID: 34325446 DOI: 10.1097/ccm.0000000000005208] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
- Division of Primary Care and Population Health, Department of Medicine, Palliative Care Section, Stanford University, Stanford, CA
| | - Christopher E Cox
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Judith G Baggs
- School of Nursing, Oregon Health & Science University, Portland, OR
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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Outcomes of ICU patients with and without perceptions of excessive care: a comparison between cancer and non-cancer patients. Ann Intensive Care 2021; 11:120. [PMID: 34331626 PMCID: PMC8325749 DOI: 10.1186/s13613-021-00895-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/29/2021] [Indexed: 11/23/2022] Open
Abstract
Background Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer. Methods This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer. Results Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p < 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60–1.72 and HR 0.87, 95% CI 0.49–1.54) and TLDs (HR 0.81, 95% CI 0.33–1.99 and HR 0.70, 95% CI 0.27–1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58–3.15 and 1.66, 95% CI 1.28–2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups. Conclusions The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00895-5.
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18
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Lim A, Kim S. Nurses' ethical decision-making during end of life care in South Korea: a cross-sectional descriptive survey. BMC Med Ethics 2021; 22:94. [PMID: 34271891 PMCID: PMC8285824 DOI: 10.1186/s12910-021-00665-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/09/2021] [Indexed: 11/11/2022] Open
Abstract
Background Although nurses are crucial to ensure patients’ peaceful death in hospitals, many nurses experience various ethical conflicts during end-of-life care. Therefore, research on nurses’ entire ethical decision-making process is required to improve nurses’ ethical decision-making in end-of-life care. This study aimed to identify Korean nurses’ ethical decision-making process based on their moral sensitivity to end-of-life patients. Methods In total, 171 nurses caring for terminal patients responded to the survey questionnaire. To measure the participants’ moral sensitivity and ethical decision-making process, we used the Korean version of the Moral Sensitivity Questionnaire and Nurses’ Ethical Decision-Making around End of Life Care Scale. Finally, multiple linear regression analysis was used to investigate the effect of moral sensitivity on nurses’ ethical decision-making. Results The mean of moral sensitivity was 4.8 ± 0.5 (out of 7), and that of ethical decision-making was 4.6 ± 0.5 (out of 6). Among the sub-dimensions of ethical decision-making, the highest score was in perceived professional accountability (5.2 ± 0.5), and the lowest in moral reasoning and moral agency (3.9 ± 0.6); the score of moral practice was 4.4 ± 0.7. In the multiple linear regression model, moral sensitivity (β = 0.852, p < .001), clinical department (β = − 7.018, p = .035), ethics education (β = 20.450, p < .001), job satisfaction (β = 5.273, p < .001), and ethical conflict (β = − 2.260, p = 0.031) were influential ethical decision-making factors. Conclusions This study revealed a gap between nurses’ thoughts and practices through the ethical decision-making process. They failed to lead their thought to moral practice. It also implies that moral sensitivity could positively affect nurses’ ethical decision-making. To make nurses morally sensitive, exposing them to various clinical cases would be helpful. Additionally, ethics education and clinical ethics supporting services are valuable for improving nurses’ ethical decision-making. If nurses improved their ethical decision-making regarding end-of-life care, their patients could experience a better quality of death.
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Affiliation(s)
- Arum Lim
- Department of Nursing, Graduate School, Yonsei University, Seoul, Korea
| | - Sanghee Kim
- College of Nursing and, Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
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Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study. J Clin Med 2021; 10:jcm10143068. [PMID: 34300235 PMCID: PMC8305175 DOI: 10.3390/jcm10143068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. Objectives: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. Method: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. Results: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient’s comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from −0.05 to 0.42 for patients with advanced disease, and from −0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. Conclusion: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.
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Donkers MA, Gilissen VJHS, Candel MJJM, van Dijk NM, Kling H, Heijnen-Panis R, Pragt E, van der Horst I, Pronk SA, van Mook WNKA. Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study. BMC Med Ethics 2021; 22:73. [PMID: 34139997 PMCID: PMC8211309 DOI: 10.1186/s12910-021-00641-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 05/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background The COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19. Methods An extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19.
Results Three hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. “Inadequate emotional support for patients and their families” was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect, ethical awareness and support. “Culture of not avoiding end-of-life-decisions” and “Self-reflective and empowering leadership” received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses (p < 0.001) and intensivists (p < 0.05) compared to one year prior. Conclusion Levels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00641-3.
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Affiliation(s)
- Moniek A Donkers
- Department of Intensive Care, Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Vincent J H S Gilissen
- Department of Intensive Care, Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Math J J M Candel
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Nathalie M van Dijk
- Department of Intensive Care, Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Hans Kling
- Department of Spiritual Care Services, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ruth Heijnen-Panis
- Department of Intensive Care, Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Elien Pragt
- Department of Intensive Care, Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Iwan van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Sebastiaan A Pronk
- Department of Intensive Care, Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Walther N K A van Mook
- Department of Intensive Care, Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.,Academy for Postgraduate Medical Training, Maastricht University Medical Center+, Maastricht, The Netherlands.,School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
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21
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Silverman HJ, Kheirbek RE, Moscou-Jackson G, Day J. Moral distress in nurses caring for patients with Covid-19. Nurs Ethics 2021; 28:1137-1164. [PMID: 33910406 DOI: 10.1177/09697330211003217] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Moral distress occurs when constraints prevent healthcare providers from acting in accordance with their core moral values to provide good patient care. The experience of moral distress in nurses might be magnified during the current Covid-19 pandemic. OBJECTIVE To explore causes of moral distress in nurses caring for Covid-19 patients and identify strategies to enhance their moral resiliency. RESEARCH DESIGN A qualitative study using a qualitative content analysis of focus group discussions and in-depth interviews. We purposively sampled 31 nurses caring for Covid-19 patients in the acute care units within large academic medical systems in Maryland and New York City during April to June 2020. ETHICAL CONSIDERATIONS We obtained approval from the Institutional Review Board at the University of Maryland, Baltimore. RESULTS We identified themes and sub-themes representative of major causes of moral distress in nurses caring Covid-19 patients. These included (a) lack of knowledge and uncertainty regarding how to treat a new illness; (b) being overwhelmed by the depth and breadth of the Covid-19 illness; (c) fear of exposure to the virus leading to suboptimal care; (d) adopting a team model of nursing care that caused intra-professional tensions and miscommunications; (e) policies to reduce viral transmission (visitation policy and PPE policy) that prevented nurses to assume their caring role; (f) practicing within crisis standards of care; and (g) dealing with medical resource scarcity. Participants discussed their coping mechanisms and suggested future strategies. DISCUSSION/CONCLUSION Our study affirms new causes of moral distress related to the Covid-19 pandemic. Institutions need to develop a supportive ethical climate that can restore nurses' moral resiliency. Such a climate should include non-hierarchical interdisciplinary spaces where all providers can meet together as moral peers to discuss their experiences.
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Affiliation(s)
| | | | | | - Jenni Day
- 1479University of Maryland Medical Center, USA
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22
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Robertsen A, Helseth E, Førde R. Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see. BMC Med Ethics 2021; 22:43. [PMID: 33849500 PMCID: PMC8043091 DOI: 10.1186/s12910-021-00612-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient's best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians' strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. METHODS Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians' strategies related to treatment-limiting decision-making. RESULTS A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital's strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team-family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The "wait-and-see" physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. CONCLUSIONS Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.
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Affiliation(s)
- Annette Robertsen
- Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Eirik Helseth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Reidun Førde
- Centre of Medical Ethics, University of Oslo, Oslo, Norway
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Moynihan KM, Taylor L, Crowe L, Balnaves MC, Irving H, Ozonoff A, Truog RD, Jansen M. Ethical climate in contemporary paediatric intensive care. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106818. [PMID: 33431646 DOI: 10.1136/medethics-2020-106818] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/27/2020] [Accepted: 12/03/2020] [Indexed: 06/12/2023]
Abstract
Ethical climate (EC) has been broadly described as how well institutions respond to ethical issues. Developing a tool to study and evaluate EC that aims to achieve sustained improvements requires a contemporary framework with identified relevant drivers. An extensive literature review was performed, reviewing existing EC definitions, tools and areas where EC has been studied; ethical challenges and relevance of EC in contemporary paediatric intensive care (PIC); and relevant ethical theories. We surmised that existing EC definitions and tools designed to measure it fail to capture nuances of the PIC environment, and sought to address existing gaps by developing an EC framework for PIC founded on ethical theory. In this article, we propose a Paediatric Intensive Care Ethical Climate (PICEC) conceptual framework and four measurable domains to be captured by an assessment tool. We define PICEC as the collective felt experience of interdisciplinary team members arising from those factors that enable or constrain their ability to navigate ethical aspects of their work. PICEC both results from and is influenced by how well ethical issues are understood, identified, explored, reflected on, responded to and addressed in the workplace. PICEC encompasses four, core inter-related domains representing drivers of EC including: (1) organisational culture and leadership; (2) interdisciplinary team relationships and dynamics; (3) integrated child and family-centred care; and (4) ethics literacy. Future directions involve developing a PICEC measurement tool, with implications for benchmarking as well as guidance for, and evaluation of, targeted interventions to foster a healthy EC.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Taylor
- Office of Ethics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Liz Crowe
- Department of Pediatric Intensive Care, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Mary-Claire Balnaves
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Helen Irving
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Centre for Children's Health Ethics and Law, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Al Ozonoff
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Melanie Jansen
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Pediatric Intensive Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
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24
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Griffiths F, Svantesson M, Bassford C, Dale J, Blake C, McCreedy A, Slowther AM. Decision-making around admission to intensive care in the UK pre-COVID-19: a multicentre ethnographic study. Anaesthesia 2020; 76:489-499. [PMID: 33141939 DOI: 10.1111/anae.15272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2020] [Indexed: 12/24/2022]
Abstract
Predicting who will benefit from admission to an intensive care unit is not straightforward and admission processes vary. Our aim was to understand how decisions to admit or not are made. We observed 55 decision-making events in six NHS hospitals. We interviewed 30 referring and 43 intensive care doctors about these events. We describe the nature and context of the decision-making and analysed how doctors make intensive care admission decisions. Such decisions are complex with intrinsic uncertainty, often urgent and made with incomplete information. While doctors aspire to make patient-centred decisions, key challenges include: being overworked with lack of time; limited support from senior staff; and a lack of adequate staffing in other parts of the hospital that may be compromising patient safety. To reduce decision complexity, heuristic rules based on experience are often used to help think through the problem; for example, the patient's functional status or clinical gestalt. The intensive care doctors actively managed relationships with referring doctors; acted as the hospital generalist for acutely ill patients; and brought calm to crisis situations. However, they frequently failed to elicit values and preferences from patients or family members. They were rarely explicit in balancing burdens and benefits of intensive care for patients, so consistency and equity cannot be judged. The use of a framework for intensive care admission decisions that reminds doctors to seek patient or family views and encourages explicit balancing of burdens and benefits could improve decision-making. However, a supportive, adequately resourced context is also needed.
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Affiliation(s)
- F Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - M Svantesson
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
| | - C Bassford
- Department of Intensive Care Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - J Dale
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - C Blake
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - A McCreedy
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - A-M Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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25
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Chan HY. Remapping the organ donation ethical climate: a care ethics consideration. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2020; 23:295-308. [PMID: 31811525 DOI: 10.1007/s11019-019-09934-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Organ donation has gained much attention as the need for transplant exceeds the supply of organs. Various proposals have been put forward to address the organ shortage challenge, ranging from offering incentives to donors, addressing family refusals to donations and instituting presumed consent laws. Presumed consent as the favoured approach has not been universally effective in increasing actual transplants despite its appeal. Few considerations have been given to the broader ethical climate influencing the organ donation debate. This paper examines the ethical climate surrounding organ donation and identifies the challenges existing within such environments. It explores care ethics and its application to the donation system, demonstrating how it can influence the organ donation phases. The conclusion drawn from the analysis is that a caring ethical climate in the pre, during and post-transplant system respects donor autonomy, addresses family reluctance to agree to donation, facilitates the needs of the donee and creates an environment that promotes non-maleficence for all stakeholders.
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Perceptions of Ethical Decision-Making Climate Among Clinicians Working in European and U.S. ICUs: Differences Between Nurses and Physicians. Crit Care Med 2020; 47:1716-1723. [PMID: 31625980 DOI: 10.1097/ccm.0000000000004017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses' and physicians' rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses. DESIGN Prospective observational study. SETTING A total of 68 adult ICUs in 13 European countries and the United States. SUBJECTS ICU physicians and nurses. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses' involvement at end-of-life, average without nurses' involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions. CONCLUSIONS Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies.
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Interprofessional Shared Decision-Making in the ICU: A Systematic Review and Recommendations From an Expert Panel. Crit Care Med 2020; 47:1258-1266. [PMID: 31169620 DOI: 10.1097/ccm.0000000000003870] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation. DATA SOURCES We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making. STUDY SELECTION Three authors screened titles and abstracts in duplicate. DATA SYNTHESIS Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs. CONCLUSIONS Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.
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Van den Bulcke B, Metaxa V, Reyners AK, Rusinova K, Jensen HI, Malmgren J, Darmon M, Talmor D, Meert AP, Cancelliere L, Zubek L, Maia P, Michalsen A, Kompanje EJO, Vlerick P, Roels J, Vansteelandt S, Decruyenaere J, Azoulay E, Vanheule S, Piers R, Benoit D. Ethical climate and intention to leave among critical care clinicians: an observational study in 68 intensive care units across Europe and the United States. Intensive Care Med 2019; 46:46-56. [PMID: 31690968 PMCID: PMC6954133 DOI: 10.1007/s00134-019-05829-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/10/2019] [Indexed: 11/13/2022]
Abstract
Purpose Apart from organizational issues, quality of inter-professional collaboration during ethical decision-making may affect the intention to leave one’s job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics. Methods Perceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self-assessment questionnaire, together with job characteristics and intent to leave as a sub-analysis of the Dispropricus study. The validated ethical decision-making climate questionnaire included seven factors: not avoiding decision-making at end-of-life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self-reflective physician leadership, active decision-making at end-of-life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within ICUs, within the different countries. Results Of 3610 nurses and 1137 physicians providing ICU bedside care, 63.1% and 62.9% participated, respectively. Of 2992 participating clinicians, 782 (26.1%) had intent to leave, of which 27% nurses, 24% junior and 22.7% senior physicians. After adjustment for country, ICU and clinicians characteristics, mutual respect OR 0.77 (95% CI 0.66- 0.90), open interdisciplinary reflection (OR 0.73 [95% CI 0.62–0.86]) and not avoiding EOL decisions (OR 0.87 [95% CI 0.77–0.98]) were all associated with a lower intent to leave. Conclusion This is the first large multicenter study showing an independent association between clinicians’ intent to leave and the quality of the ethical climate in the ICU. Interventions to reduce intent to leave may be most effective when they focus on improving mutual respect, interdisciplinary reflection and active decision-making at EOL. Electronic supplementary material The online version of this article (10.1007/s00134-019-05829-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bo Van den Bulcke
- Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium.
| | | | - Anna K Reyners
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Katerina Rusinova
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Hanne I Jensen
- Department of Intensive Care Medicine, Institute of Regional Research, Vejle Hospital, Vejle, Denmark
| | - J Malmgren
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.,University of Southern Denmark, Odense, Denmark
| | - Michael Darmon
- Hôpital Saint-Louis and University Paris-7, Paris, France
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Anne-Pascale Meert
- Service des Medicine Interne, Soins Intensifs et Urgences Oncologiques, Institut Jules Bordet, ULB, Brussels, Belgium
| | - Laura Cancelliere
- SCDU Anestesia e Rianimazione, Azienda and Ospedaliero Universitaria, Maggiore della Carità, Novara, Italy
| | - László Zubek
- Semmelweis University Budapest, Budapest, Hungary
| | - Paulo Maia
- Intensive Care Department, Hospital S.António, Porto, Portugal
| | | | - Erwin J O Kompanje
- Department of Intensive Care Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter Vlerick
- Faculty of Psychology and Educational Sciences, Department of Personnel Management, Work and Organizational Psychology, Ghent University, Ghent, Belgium
| | - Jolien Roels
- Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium
| | - Stijn Vansteelandt
- Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium.,London School of Hygiene and Tropical Medicine, London, UK
| | - Johan Decruyenaere
- Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium
| | - Elie Azoulay
- Hôpital Saint-Louis and University Paris-7, Paris, France
| | - Stijn Vanheule
- Department of Psycho-analysis and Clinical Consulting, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominique Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium
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Robertsen A, Helseth E, Laake JH, Førde R. Neurocritical care physicians' doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: an interview study. Scand J Trauma Resusc Emerg Med 2019; 27:81. [PMID: 31462245 PMCID: PMC6714084 DOI: 10.1186/s13049-019-0648-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/19/2019] [Indexed: 11/15/2022] Open
Abstract
Background Multilevel uncertainty exists in the treatment of devastating brain injury and variation in end-of-life decision-making is a concern. Cognitive and emotional doubt linked to making challenging decisions have not received much attention. The aim of this study was to explore physicians´ doubt related to decisions to withhold or withdraw life-sustaining treatment within the first 72 h after devastating brain injury and to identify the strategies used to address doubt. Method Semi-structured interviews were conducted with 18 neurocritical care physicians in a Norwegian trauma centre (neurosurgeons, intensivists and rehabilitation specialists) followed by a qualitative thematic analysis. Result All physicians described feelings of doubt. The degree of doubt and how they dealt with it varied. Institutional culture, ethics climate and individual physicians´ values, experiences and emotions seemed to impact judgements and decisions. Common strategies applied by physicians across specialities when dealing with uncertainty and doubt were: 1. Provision of treatment trials 2. Using time as a coping strategy 3. Collegial counselling and interdisciplinary consensus seeking 4. Framing decisions as purely medical. Conclusion Decisions regarding life-sustaining treatment after devastating brain injury are crafted in a stepwise manner. Feelings of doubt are frequent and seem to be linked to the recognition of fallibility. Doubt can be seen as positive and can foster open-mindedness towards the view of others, which is one of the prerequisites for a good ethical climate. Doubt in this context tends to be mitigated by open interdisciplinary discussions acknowledging doubt as rational and a normal feature of complex decision-making.
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Affiliation(s)
- Annette Robertsen
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. .,Department of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Eirik Helseth
- Department of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Jon Henrik Laake
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Reidun Førde
- Centre of Medical Ethics, University of Oslo, Oslo, Norway
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30
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‘I cried too’ – Allowing ICU nurses to grieve when patients die. Intensive Crit Care Nurs 2019; 52:1-2. [DOI: 10.1016/j.iccn.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2019] [Indexed: 12/30/2022]
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Houchens N, Gupta A, Meddings J. Quality & safety in the literature: May 2019. BMJ Qual Saf 2019; 28:424-428. [PMID: 30842266 DOI: 10.1136/bmjqs-2019-009401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 01/30/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Nathan Houchens
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA .,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer Meddings
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
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McAndrew NS, Schiffman R, Leske J. Relationships among Climate of Care, Nursing Family Care and Family Well-being in ICUs. Nurs Ethics 2019; 26:2494-2510. [PMID: 30832534 DOI: 10.1177/0969733019826396] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Frequent exposure to ethical conflict and a perceived lack of organizational support to address ethical conflict may negatively influence nursing family care in the intensive care unit. RESEARCH AIMS The specific aims of this study were to determine: (1) if intensive care unit climate of care variables (ethical conflict, organizational resources for ethical conflict, and nurse burnout) were predictive of nursing family care and family wellbeing and (2) direct and indirect effects of the climate of care on the quality of nursing family care and family wellbeing. RESEARCH DESIGN A cross-sectional, correlational design was used. PARTICIPANTS AND RESEARCH CONTEXT Convenience sample of 111 nurses and 44 family members from five intensive care units at a Midwest hospital in the United States. INSTRUMENTS The Ethical Conflict Questionnaire-Critical Care Version, Maslach Burnout Inventory-Human Services Survey and Hospital Ethical Climate Scale were used to measure climate of care. The Family-Centered Care-Adult Version and Nurse Provided Family Social Support Scale were family measures of the quality of nursing family care. The Family Wellbeing Index was used to measure family wellbeing. DATA ANALYSIS Hierarchical regression and mediation analysis were used to answer the study aims. ETHICAL CONSIDERATIONS The study was approved by the Institutional Review Board at the study site. FINDINGS In separate regression models, organizational resources for ethical conflict (β = .401, p = .006) and depersonalization (β = -.511, p = .006), a component of burnout, were significant predictors of family-centered care. In simple mediation analysis the relationship between organizational resources for ethical conflict and family-centered care was mediated by depersonalization (β = .341, 95% confidence interval (.015, .707)). DISCUSSION Inadequate organizational resources and depersonalization may be related to family care delivery, and present obstacles to family-centered care in the intensive care unit. CONCLUSION Further research to explicate the relationships among organizational resources, ethical conflict, burnout, and family-centered care is needed to guide the development of effective interventions that enhance the quality of nursing family care in the intensive care unit.
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Affiliation(s)
| | | | - Jane Leske
- Froedtert & the Medical College of Wisconsin Froedtert Hospital
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Okenyi E, Donaldson TM, Collins A, Morton B, Obasi A. Assessing ethical climates in critical care and their impact on patient outcomes. Breathe (Sheff) 2019; 15:84-87. [PMID: 30838066 PMCID: PMC6395987 DOI: 10.1183/20734735.0335-2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Intensive care units with a "good" ethical environment are more likely to identify perceived excessive patient care. Patients with perceived excessive care were more likely to die and time to death was shorter in units with a "good" ethical environment. http://ow.ly/vnFP30neAZN.
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Affiliation(s)
- Emmanuel Okenyi
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.,Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Andrea Collins
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.,Liverpool School of Tropical Medicine, Liverpool, UK.,Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Ben Morton
- Liverpool School of Tropical Medicine, Liverpool, UK.,Aintree University Hospital NHS Foundation Trust, Liverpool, UK.,Both authors contributed equally
| | - Angela Obasi
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.,Liverpool School of Tropical Medicine, Liverpool, UK.,Both authors contributed equally
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Interprofessional teamwork, quality of care and turnover intention in geriatric care: A cross-sectional study in 55 acute geriatric units. Int J Nurs Stud 2019; 91:94-100. [DOI: 10.1016/j.ijnurstu.2018.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/01/2018] [Accepted: 11/24/2018] [Indexed: 11/20/2022]
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The prevalence of perceptions of mismatch between treatment intensity and achievable goals of care in the intensive care unit: a cross-sectional study. Intensive Care Med 2019; 45:459-467. [DOI: 10.1007/s00134-019-05543-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/22/2019] [Indexed: 11/26/2022]
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Guidet B, Vallet H, Boddaert J, de Lange DW, Morandi A, Leblanc G, Artigas A, Flaatten H. Caring for the critically ill patients over 80: a narrative review. Ann Intensive Care 2018; 8:114. [PMID: 30478708 PMCID: PMC6261095 DOI: 10.1186/s13613-018-0458-7] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/14/2018] [Indexed: 12/25/2022] Open
Abstract
Background There is currently no international recommendation for the admission or treatment of the critically ill older patients over 80 years of age in the intensive care unit (ICU), and there is no valid prognostic severity score that includes specific geriatric assessments. Main body In this review, we report recent literature focusing on older critically ill patients in order to help physicians in the multiple-step decision-making process. It is unclear under what conditions older patients may benefit from ICU admission. Consequently, there is a wide variation in triage practices, treatment intensity levels, end-of-life practices, discharge practices and frequency of geriatrician’s involvement among institutions and clinicians. In this review, we discuss important steps in caring for critically ill older patients, from the triage to long-term outcome, with a focus on specific conditions in the very old patients. Conclusion According to previous considerations, we provide an algorithm presented as a guide to aid in the decision-making process for the caring of the critically ill older patients. Electronic supplementary material The online version of this article (10.1186/s13613-018-0458-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bertrand Guidet
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Réanimation Médicale, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France. .,Sorbonne Universités, Université Pierre et Marie Curie - Paris 06, Paris, France. .,INSERM, UMR_S 1136, Institute Pierre Louis d'Épidémiologie et de Santé Publique, 75013, Paris, France.
| | - Helene Vallet
- INSERM, UMR_S 1136, Institute Pierre Louis d'Épidémiologie et de Santé Publique, 75013, Paris, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de gériatrie, Hôpital Pitié salpêtrière, 75013, Paris, France
| | - Jacques Boddaert
- Sorbonne Universités, Université Pierre et Marie Curie - Paris 06, Paris, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de gériatrie, Hôpital Pitié salpêtrière, 75013, Paris, France
| | - Dylan W de Lange
- Department of Intensive Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Alessandro Morandi
- Department of Rehabilitation Hospital Ancelle di Cremona, Cremona, Italy.,Geriatric Research Group, Brescia, Italy
| | - Guillaume Leblanc
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Centre de recherche du CHU de Québec - Université Laval, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Québec City, QC, Canada
| | - Antonio Artigas
- Department of Intensive Care Medecine, CIBER EnfermedadesRespiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Hartog CS, Hoffmann F, Mikolajetz A, Schröder S, Michalsen A, Dey K, Riessen R, Jaschinski U, Weiss M, Ragaller M, Bercker S, Briegel J, Spies C, Schwarzkopf D. [Non-beneficial therapy and emotional exhaustion in end-of-life care : Results of a survey among intensive care unit personnel]. Anaesthesist 2018; 67:850-858. [PMID: 30209513 DOI: 10.1007/s00101-018-0485-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/20/2018] [Accepted: 08/27/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play a role in the context of EOLC. OBJECTIVE Is the working environment associated with perception of NBT or clinician burnout? MATERIAL AND METHODS Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis. RESULTS The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91 residents and 26 consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p ≤ 0.001) and the numbers of weekend working days per month (p = 0.012). Protective factors against burnout included intensive care specialization (p = 0.001) and emotional support within the team (p ≤ 0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p ≤ 0.001). DISCUSSION Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.
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Affiliation(s)
- Christiane S Hartog
- Klinik für Anästhesie m.S. operative Intensivmedizin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
- Klinik Bavaria Kreischa, Kreischa, Deutschland.
| | - F Hoffmann
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinik Jena, Jena, Deutschland
| | - A Mikolajetz
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinik Jena, Jena, Deutschland
| | - S Schröder
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Krankenhaus Düren, Düren, Deutschland
| | - A Michalsen
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Medizin Campus Bodensee - Klinik Tettnang, Tettnang, Deutschland
| | - K Dey
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Bundeswehrkrankenhaus Berlin, Berlin, Deutschland
| | - R Riessen
- Medizinische Klinik, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - U Jaschinski
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Augsburg, Deutschland
| | - M Weiss
- Klinik für Anästhesiologie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - M Ragaller
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Deutschland
| | - S Bercker
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - J Briegel
- Klinik für Anästhesiologie, Klinikum der Universität, LMU München, München, Deutschland
| | - C Spies
- Klinik für Anästhesie m.S. operative Intensivmedizin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - D Schwarzkopf
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinik Jena, Jena, Deutschland
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Bion J, Antonelli M, Blanch LL, Curtis JR, Druml C, Du B, Machado FR, Gomersall C, Hartog C, Levy M, Myburgh J, Rubenfeld G, Sprung C. White paper: statement on conflicts of interest. Intensive Care Med 2018; 44:1657-1668. [PMID: 30191294 DOI: 10.1007/s00134-018-5349-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/14/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Conflicts of interest are a normal part of human social intercourse. They become problematic when there is a power differential between participants in the setting of relationships requiring a high degree of trust, as in healthcare. In this white paper we consider how these conflicts may be detected and mitigated. METHODS Following Medline search and reference chaining, we undertook a narrative review of the literature with iterative discussion. RESULTS Conflicts of interest may be financial, professional or personal, and may operate at the level of the individual or the organisation. Unmanaged, they become a source of bias which places the interests of the professional or the organisation before those of the patient. Reported with increasing frequency, conflicts damage trust, harm patients, and defraud the health system. We make 15 recommendations for minimising conflicts of interest. CONCLUSIONS Nationally funded open-access registries should be established to permit complete disclosure of financial, professional, and personal relationships with the potential for driving bias in research, clinical practice, or health management. Governance of disclosure should be the responsibility of employing organisations through annual staff appraisals, audited by national research integrity committees. Research fraud should incur suspension of the license to practice. Organisations should monitor staff perceptions of ethical climate to enhance awareness of staff behaviours and the potential for misconduct driven by academic pressures. Clear separation of advisory and voting roles is needed in best practice guideline panels. Professional societies and scientific journals should display conflict of interest policies for their own staff and officers as well as for speakers and authors. Undergraduates should not be exposed to pharmaceutical promotions masquerading as education. Undergraduate and postgraduate training programmes should include teaching about managing conflicts of interest and identifying research misconduct.
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Affiliation(s)
- Julian Bion
- University Department of Intensive Care Medicine, University of Birmingham, Ground Floor East Wing, Queen Elizabeth Hospital (Heritage Site), Birmingham, B15 2GW, UK.
| | - Massimo Antonelli
- Department of Intensive Care Medicine, Anesthesiology and Emergency Medicine, Fondazione Policlicnico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - LLuis Blanch
- Parc Tauli University Hospital, CIBER Enfermedades Respiratorias, Institut de Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA, 98104, USA
| | - Christiane Druml
- UNESCO Chair on Bioethics of the Medical University of Vienna, Ethics, Collections and History of Medicine, Waehringerstrasse 25, 1090, Vienna, Austria
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medicine College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, China
| | - Flavia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Charles Gomersall
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Christiane Hartog
- Department of Anaesthesiology and Intensive Care Medicine, Centre for Sepsis Care and Control, Jena University Hospital, 07747, Jena, Germany
| | - Mitchell Levy
- Pulmonary and Critical Care Medicine Alpert Medical School of Brown University, Rhode Island Hospital, Providence, USA
| | - John Myburgh
- The George Institute for Global Health, Level 5, 1 King St, Newtown, NSW, 2042, Australia
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, 2075 Bayview Avenue, Room D108c, Toronto, ON, M4N 3M5, Canada
| | - Charles Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Beet C, Benoit D, Bion J. Intensive care medicine in 2050: preventing harm. Intensive Care Med 2018; 45:505-507. [PMID: 30178134 DOI: 10.1007/s00134-018-5353-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/21/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Chris Beet
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
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Turnbull AE, Sahetya SK, Biddison ELD, Hartog CS, Rubenfeld GD, Benoit DD, Guidet B, Gerritsen RT, Tonelli MR, Curtis JR. Competing and conflicting interests in the care of critically ill patients. Intensive Care Med 2018; 44:1628-1637. [PMID: 30046872 DOI: 10.1007/s00134-018-5326-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/16/2018] [Indexed: 12/26/2022]
Abstract
Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician's sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient's best interest and discusses steps that could help minimize the impact of these factors on patient care.
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Affiliation(s)
- Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA. .,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. .,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA
| | - E Lee Daugherty Biddison
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA
| | - Christiane S Hartog
- Department for Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany.,Department of Anaesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Kreischa, Germany.,Patient- and Family-Centered Care, Klinik Bavaria, Kreischa, Germany
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Bertrand Guidet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France.,Sorbonne Universités, Université Pierre et Marie Curie, Paris, France.,Institut National de la Santé et de la Recherche Médicale (INSERM), UMR S 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
| | - Rik T Gerritsen
- Department of Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Mark R Tonelli
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
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Brown SM, Talmor D, Howell MD. Building communities of respect in the intensive care unit. Intensive Care Med 2018; 44:1339-1341. [PMID: 29961105 DOI: 10.1007/s00134-018-5259-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/01/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Samuel M Brown
- Center for Humanizing Critical Care, Intermountain Medical Center and Department of Internal Medicine, University of Utah School of Medicine, Murray, UT, USA.
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Benoit DD, Jensen HI, Malmgren J, Metaxa V, Reyners AK, Darmon M, Rusinova K, Talmor D, Meert AP, Cancelliere L, Zubek L, Maia P, Michalsen A, Vanheule S, Kompanje EJO, Decruyenaere J, Vandenberghe S, Vansteelandt S, Gadeyne B, Van den Bulcke B, Azoulay E, Piers RD. 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 Med 2018; 44:1039-1049. [PMID: 29808345 PMCID: PMC6061457 DOI: 10.1007/s00134-018-5231-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/14/2018] [Indexed: 01/01/2023]
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. Electronic supplementary material The online version of this article (10.1007/s00134-018-5231-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- D D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - H I Jensen
- Department of Intensive Care Medicine, Vejle Hospital, Vejle, Denmark
- Institute of Regional Research, University of Southern Denmark, Odense C, Denmark
| | - J Malmgren
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - V Metaxa
- King's College Hospital, London, UK
| | - A K Reyners
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M Darmon
- Hôpital Saint-Louis and University, Paris-7, Paris, France
| | - K Rusinova
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - D Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - A P Meert
- Service des soins intensifs et urgences oncologiques, Institut Jules Bordet, ULB, Brussels, Belgium
| | - L Cancelliere
- SCDU Anestesia e Rianimazione, Azienda and Ospedaliero Universitaria, "Maggiore della Carità", Novara, Italy
| | - L Zubek
- Semmelweis University Budapest, Budapest, Hungary
| | - P Maia
- Intensive Care Department, Hospital S.António, Porto, Portugal
| | | | - S Vanheule
- Department of Psycho-analysis and Clinical Consulting, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - E J O Kompanje
- Department of Intensive Care Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J Decruyenaere
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - S Vandenberghe
- Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium
| | - S Vansteelandt
- Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium
- London School of Hygiene and Tropical Medicine, London, UK
| | - B Gadeyne
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - B Van den Bulcke
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - E Azoulay
- Hôpital Saint-Louis and University, Paris-7, Paris, France
| | - R D Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
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Dzeng E, Curtis JR. Understanding ethical climate, moral distress, and burnout: a novel tool and a conceptual framework. BMJ Qual Saf 2018; 27:766-770. [PMID: 29669857 DOI: 10.1136/bmjqs-2018-007905] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Elizabeth Dzeng
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA.,Department of Social and Behavioural Science, Sociology Program, University of California San Francisco, San Francisco, California, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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