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Kelly D, Barrett J, Brand G, Leech M, Rees C. Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review. Aust Crit Care 2024:S1036-7314(24)00049-3. [PMID: 38609749 DOI: 10.1016/j.aucc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. AIM The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. DESIGN Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. METHODS Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. RESULTS Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. CONCLUSION Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.
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Affiliation(s)
- Diane Kelly
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia.
| | - Jonathan Barrett
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia
| | - Gabrielle Brand
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Frankston, VIC, Australia
| | - Michelle Leech
- Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Charlotte Rees
- Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; School of Health Sciences, College of Medicine, Nursing & Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
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Sridharan G, Fleury Y, Hergafi L, Doll S, Ksouri H. Triage of Critically Ill Patients: Characteristics and Outcomes of Patients Refused as Too Well for Intensive Care. J Clin Med 2023; 12:5513. [PMID: 37685579 PMCID: PMC10488145 DOI: 10.3390/jcm12175513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The appropriate selection of patients for the intensive care unit (ICU) is a concern in acute care settings. However, the description of patients deemed too well for the ICU has been rarely reported. METHODS We conducted a single-centre retrospective observational study of all patients either deemed "too well" for or admitted to the ICU during one year. Refused patients were screened for unexpected events within 7 days, defined as either ICU admission without another indication, or death without treatment limitations. Patients' characteristics and organisational factors were analysed according to refusal status, outcome and delay in ICU admission. RESULTS Among 2219 enrolled patients, the refusal rate was 10.4%. Refusal was associated with diagnostic groups, treatment limitations, patients' location on a ward, night time and ICU occupancy. Unexpected events occurred in 16 (6.9%) refused patients. A worse outcome was associated with time spent in hospital before refusal, patients' location on a ward, SOFA score and physician's expertise. Delayed ICU admissions were associated with ICU and hospital length of stay. CONCLUSIONS ICU triage selected safely most patients who would have probably not benefited from the ICU. We identified individual and organisational factors associated with ICU refusal, subsequent ICU admission or death.
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Affiliation(s)
- Govind Sridharan
- Department of Intensive Care Medicine, Fribourg Hospital, CH-1700 Fribourg, Switzerland; (Y.F.); (L.H.); (S.D.); (H.K.)
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Valley TS, Schutz A, Miller J, Miles L, Lipman K, Eaton TL, Kinni H, Cooke CR, Iwashyna TJ. Hospital factors that influence ICU admission decision-making: a qualitative study of eight hospitals. Intensive Care Med 2023; 49:505-516. [PMID: 36952016 PMCID: PMC10035493 DOI: 10.1007/s00134-023-07031-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/06/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE Some hospitals in the United States (US) use intensive care 20 times more than others. Since intensive care is lifesaving for some but potentially harmful for others, there is a need to understand factors that influence how intensive care unit (ICU) admission decisions are made. METHODS A qualitative analysis of eight US hospitals was conducted with semi-structured, one-on-one interviews supplemented by site visits and clinical observations. RESULTS A total of 87 participants (24 nurses, 52 physicians, and 11 other staff) were interviewed, and 40 h were spent observing ICU operations across the eight hospitals. Four hospital-level factors were identified that influenced ICU admission decision-making. First, availability of intermediate care led to reallocation of patients who might otherwise be sent to an ICU. Second, participants stressed the importance of ICU nurse availability as a key modifier of ICU capacity. Patients cared for by experienced general care physicians and nurses were less likely to receive ICU care. Third, smaller or rural hospitals opted for longer emergency department patient-stays over ICU admission to expedite interhospital transfer of critically ill patients. Fourth, lack of clarity in ICU admission policies led clinicians to feel pressured to use ICU care for patients who might otherwise not have received it. CONCLUSION Health care systems should evaluate their use of ICU care and establish institutional patterns that ensure ICU admission decisions are patient-centered but also account for resources and constraints particular to each hospital.
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Affiliation(s)
- Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Building 16-G019W, Ann Arbor, MI, 48109, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- VA Center for Clinical Management Research, Ann Arbor, MI, USA.
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Amanda Schutz
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Building 16-G019W, Ann Arbor, MI, 48109, USA
| | - Jacquelyn Miller
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Building 16-G019W, Ann Arbor, MI, 48109, USA
| | - Lewis Miles
- Department of Sociology, University of Michigan, Ann Arbor, MI, USA
| | - Kyra Lipman
- Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Tammy L Eaton
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Systems, Populations and Leadership, School of Nursing, University of Michigan, Ann Arbor, MI, USA
- National Clinician Scholars Program and VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Harish Kinni
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Building 16-G019W, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Theodore J Iwashyna
- Departments of Medicine and Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
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Foley C, Bloomer M, Hutchinson AM. Factors that influence intensive care admission decisions for older people: A systematic review. Aust Crit Care 2023; 36:274-84. [PMID: 35144889 DOI: 10.1016/j.aucc.2021.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/30/2021] [Accepted: 12/19/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The population worldwide is rapidly ageing, and demand for intensive care is increasing. People aged 85 years and above, known as the oldest old, are particularly vulnerable to critical illness owing to the physiological effects of ageing. Evidence surrounding admission of the oldest old to the intensive care is limited. OBJECTIVE The objective of this study was to systematically and comprehensively review and synthesise the published research investigating factors that influence decisions to admit the oldest old to the intensive care unit. METHOD This was a systematic review and narrative synthesis. Following a comprehensive search of CINAHL, Embase, and Medline databases, peer-reviewed primary research articles examining factors associated with admission or refusal to admit the oldest old to intensive care were selected. Data were extracted into tables and narratively synthesised. RESULTS Six studies met the inclusion criteria. Three studies identified factors associated with admission such as greater premorbid self-sufficiency, patient preferences, alignment between patient and physicians' goals of treatment, age less than 85 years, and absence of cancer, or previous intensive care admission. Factors associated with refusal to admit were identified in all six studies and included limited or no bed availability, level of ICU physician experience, patients being deemed too ill or too well to benefit, and older age. CONCLUSIONS Published research investigating decision-making about admission or refusal to admit the oldest old to the intensive care unit is scant. The ageing population and increasing demand for intensive care unit resources has amplified the need for greater understanding of factors that influence decisions to admit or refuse admission of the oldest old to the intensive care unit. Such knowledge may inform guidelines regarding complex practice decisions about admission of the oldest old to an intensive care unit. Such guidelines would ensure the specialty needs of this population are considered and would reduce admission decisions that might disadvantage older people.
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Chesley CF, Anesi GL, Chowdhury M, Schaubel D, Liu VX, Lane-Fall MB, Halpern SD. Characterizing Equity of Intensive Care Unit Admissions for Sepsis and Acute Respiratory Failure. Ann Am Thorac Soc 2022; 19:2044-2052. [PMID: 35830576 PMCID: PMC9743468 DOI: 10.1513/annalsats.202202-115oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022] Open
Abstract
Rationale: Patients who identify as from racial or ethnic minority groups who have sepsis or acute respiratory failure (ARF) experience worse outcomes relative to nonminority patients, but processes of care accounting for disparities are not well-characterized. Objectives: Determine whether reductions in intensive care unit (ICU) admission during hospital-wide capacity strain occur preferentially among patients who identify with racial or ethnic minority groups. Methods: This retrospective cohort among 27 hospitals across the Philadelphia metropolitan area and Northern California between 2013 and 2018 included adult patients with sepsis and/or ARF who did not require life support at the time of hospital admission. An updated model of hospital-wide capacity strain was developed that permitted determination of relationships between patient race, ethnicity, ICU admission, and strain. Results: After adjustment for demographics, disease severity, and study hospital, patients who identified as Asian or Pacific Islander had the highest adjusted ICU admission odds relative to patients who identified as White in both the sepsis and ARF populations (odds ratio, 1.09; P = 0.006 and 1.26; P < 0.001). ICU admission was also elevated for patients with ARF who identified as Hispanic (odds ratio, 1.11; P = 0.020). Capacity strain did not modify differences in ICU admission for patients who identified with a minority group in either disease population (all interactions, P > 0.05). Conclusions: Systematic differences in ICU admission patterns were observed for patients that identified as Asian, Pacific Islander, and Hispanic. However, ICU admission was not restricted from these groups, and capacity strain did not preferentially reduce ICU admission from patients identifying with minority groups. Further characterization of provider decision-making can help contextualize these findings as the result of disparate decision-making or a mechanism of equitable care.
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Affiliation(s)
- Christopher F. Chesley
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
| | - George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
| | - Doug Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Meghan B. Lane-Fall
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, and
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
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Vincent JL, Creteur J. Appropriate care for the elderly in the ICU. J Intern Med 2022; 291:458-468. [PMID: 34487587 DOI: 10.1111/joim.13371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Life expectancy is rising worldwide and increasing numbers of elderly patients are being admitted to the intensive care unit (ICU). Because ageing is associated with changes in organ function, increased frailty, reduced activities of daily living, reduced mobility, and reduced cognition, elderly patients represent a particular subgroup of ICU patients. Ethical decisions related to the appropriateness of intensive care and/or life-sustaining interventions, the withdrawing and withholding of life support, and terminal sedation are more frequent in these patients and will be discussed in this review. Such decisions must be tailored to the individual to take into consideration personal beliefs and wishes.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
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Ariyo K, Canestrini S, David AS, Ruck Keene A, Wolfrum S, Owen G. Quality of life in elderly ICU survivors before the COVID-19 pandemic: a systematic review and meta-analysis of cohort studies. BMJ Open 2021; 11:e045086. [PMID: 34635510 PMCID: PMC8506050 DOI: 10.1136/bmjopen-2020-045086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 07/20/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES The influence of age on intensive care unit (ICU) decision-making is complex, and it is unclear if it is based on expected subjective or objective patient outcomes. To address recent concerns over age-based ICU decision-making, we explored patient-assessed quality of life (QoL) in ICU survivors before the COVID-19 pandemic. DESIGN A systematic review and meta-analysis of cohort studies published between January 2000 and April 2020, of elderly patients admitted to ICUs. PRIMARY AND SECONDARY OUTCOME MEASURES We extracted data on self-reported QoL (EQ-5D composite score), demographic and clinical variables. Using a random-effect meta-analysis, we then compared QoL scores at follow-up to scores either before admission, age-matched population controls or younger ICU survivors. We conducted sensitivity analyses to study heterogeneity and bias and a qualitative synthesis of subscores. RESULTS We identified 2536 studies and included 22 for qualitative synthesis and 18 for meta-analysis (n=2326 elderly survivors). Elderly survivors' QoL was significantly worse than younger ICU survivors, with a small-to-medium effect size (d=0.35 (-0.53 and -0.16)). Elderly survivors' QoL was also significantly greater when measured slightly before ICU, compared with follow-up, with a small effect size (d=0.26 (-0.44 and -0.08)). Finally, their QoL was also marginally significantly worse than age-matched community controls, also with a small effect size (d=0.21 (-0.43 and 0.00)). Mortality rates and length of follow-up partly explained heterogeneity. Reductions in QoL seemed primarily due to physical health, rather than mental health items. CONCLUSIONS The results suggest that the proportionality of age as a determinant of ICU resource allocation should be kept under close review and that subjective QoL outcomes should inform person-centred decision -aking in elderly ICU patients. PROSPERO REGISTRATION NUMBER CRD42020181181.
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Affiliation(s)
- Kevin Ariyo
- Department of Psychological Medicine, King's College London, London, UK
| | - Sergio Canestrini
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Alex Ruck Keene
- Department of Psychological Medicine, King's College London, London, UK
- Dickson Poon School of Law, King's College London, London, UK
| | - Sebastian Wolfrum
- Medical Clinic II, Cardiology/Angiology/Intensive Care Medicine, University Hospital Schleswig Holstein, Lübeck, Germany
- Department of Emergency Medicine, University Hospital Schleswig Holstein, Lübeck, Germany
| | - Gareth Owen
- Department of Psychological Medicine, King's College London, London, UK
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Merlo F, Lepori M, Malacrida R, Albanese E, Fadda M. Physicians' Acceptance of Triage Guidelines in the Context of the COVID-19 Pandemic: A Qualitative Study. Front Public Health 2021; 9:695231. [PMID: 34395369 PMCID: PMC8360847 DOI: 10.3389/fpubh.2021.695231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022] Open
Abstract
Aims: One of the major ethical challenges posed by the Covid-19 pandemic comes in the form of fair triage decisions for critically ill patients in situations where life-saving resources are limited. In Spring 2020, the Swiss Academy of Medical Sciences (SAMS) issued specific guidelines on triage for intensive-care treatment in the context of the Covid-19 pandemic. While evidence has shown that the capacities of intensive care medicine throughout Switzerland were sufficient to take care of all critically ill patients during the first wave of the outbreak, no evidence is available regarding the acceptance of these guidelines by ICU staff. The aim of this qualitative study was to explore the acceptance and perceived implementation of the SAMS guidelines among a sample of senior physicians involved in the care of Covid-19 patients in the Canton of Ticino. Specific objectives included capturing and describing physicians' attitudes toward the guidelines, any challenges experienced in their application, and any perceived factors that facilitated or would facilitate their application. Methods: We conducted face-to-face and telephone interviews with a purposive sample of nine senior physicians employed as either head of unity, deputy-head of unit, or medical director in either one of the two Covid-19 hospitals in the Canton of Ticino during the peak of the outbreak. Interviews were transcribed verbatim and thematically analyzed using an inductive approach. Results: We found that participants held different views regarding the nature of the guidelines, saw decisions on admission as a matter of collective responsibility, argued that decisions should be based on a medical futility principle rather than an age criterion, and found that difficulties to address end-of-life issues led to a comeback of paternalism. Conclusions: Results highlight the importance of clarifying the nature of the guidelines, establishing authority, and responsibility during triaging decisions, recognizing and addressing sources of interference with patients' autonomy, and the need of a cultural shift in timely and efficiently addressing end-of-life issues.
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Affiliation(s)
- Federica Merlo
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera italiana, Lugano, Switzerland.,Sasso Corbaro Foundation, Bellinzona, Switzerland
| | - Mattia Lepori
- Ente Ospedaliero Cantonale, Area Medica Direzione Generale, Bellinzona, Switzerland
| | | | - Emiliano Albanese
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera italiana, Lugano, Switzerland
| | - Marta Fadda
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera italiana, Lugano, Switzerland
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Cullati S, Perneger TV, Scherer F, Nendaz M, Escher M. Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study. J Clin Med 2021; 10:3068. [PMID: 34300235 DOI: 10.3390/jcm10143068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Escher M, Nendaz MR, Cullati S, Hudelson P. Physicians' perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study. BMJ Open 2021; 11:e046268. [PMID: 34020978 PMCID: PMC8144032 DOI: 10.1136/bmjopen-2020-046268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The use of intensive care at the end of life can be high, leading to inappropriate healthcare utilisation, and prolonged suffering for patients and families. The objective of the study was to determine which factors influence physicians' admission decisions in situations of potentially non-beneficial intensive care. DESIGN This is a secondary analysis of a qualitative study exploring the triage process. In-depth interviews were analysed using an inductive approach to thematic content analysis. SETTING Data were collected in a Swiss tertiary care centre between March and June 2013. PARTICIPANTS 12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions. RESULTS Physicians struggled to understand the request for intensive care for patients with advanced disease and full code status. Physicians considered patients' long-term vital and functional prognosis, but they also resorted to shortcuts, that is, a priori consensus about reasons for admitting a patient. Family pressure and unexpected critical events were determinants of admission to the ICU. Patient preferences, ICU physician's expertise and collaborative decision making facilitated refusal. Physicians were willing to admit a patient with advanced disease for a limited amount of time to fulfil a personal need. CONCLUSIONS In situations of potentially non-beneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Institutional guidelines and timely goals of care discussions with patients with advanced disease and their families could contribute to ensuring appropriate levels of care.
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Affiliation(s)
- Monica Escher
- Division of Palliative Medicine, University Hospitals of Geneva, Geneva, Switzerland
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mathieu R Nendaz
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland
- Population Health Laboratory, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Patricia Hudelson
- Department of Primary Care, University Hospitals of Geneva, Geneva, Switzerland
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Putot S, Jouanny P, Barben J, Mazen E, Da Silva S, Dipanda M, Asgassou S, Nuss V, Laborde C, Mihai AM, Vovelle J, Manckoundia P, Putot A. Level of Medical Intervention in Geriatric Settings: Decision Factors and Correlation With Mortality. J Am Med Dir Assoc 2021; 22:2587-2592. [PMID: 33992608 DOI: 10.1016/j.jamda.2021.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Level of medical intervention (LMI) has to be adapted to each patient in geriatric care. LMI scales intend to help nonintensive care (NIC) decisions, giving priority to patient choice and collegial discussion. In the present study, we aimed to assess the parameters associated with the NIC decision and whether these parameters differ from those associated with in-hospital mortality. DESIGN Prospective observational study. SETTING AND PARTICIPANTS All consecutive patients from a French 62-bed acute geriatric unit over 1 year. METHODS Factors from the geriatric assessment associated with the decision of NIC were compared with those associated with in-hospital and 1-year mortality, in univariate and multivariate analyses. RESULTS In total, 1654 consecutive patients (median age 87 years) were included. Collegial reflection led to NIC decision for 532 patients (32%). In-hospital and 1-year mortality were 22% and 54% in the NIC group vs 2% and 27% in the rest of the cohort (P < .001 for both). In multivariable analysis, high Charlson Comorbidity Index [odds ratio (OR) 1.15, 95% confidence interval (CI) 1.06-1.23, per point], severe neurocognitive disorders (OR 2.78, 95% CI 1.67-4.55), dependence (OR 1.92, 95% CI 1.45-2.59), and nursing home residence (OR 2.38, 95% CI 1.85-3.13) were highly associated with NIC decision but not with in-hospital mortality. Conversely, acute diseases had little impact on LMI despite their high short-term prognostic burden. CONCLUSIONS AND IMPLICATIONS Neurocognitive disorders and dependence were strongly associated with NIC decision, even though they were not significantly associated with in-hospital mortality. The decision-making process of LMI therefore seems to go beyond the notion of short-term survival.
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Affiliation(s)
- Sophie Putot
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Pierre Jouanny
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France; Institut National de la Santé et de la Recherche Médicale U1093 Cognition Action Plasticité, Université de Bourgogne Franche-Comté, Dijon, Bourgogne Franche-Comté, France
| | - Jeremy Barben
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Emmanuel Mazen
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Sofia Da Silva
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Mélanie Dipanda
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Sanaa Asgassou
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Valentine Nuss
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Caroline Laborde
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Anca M Mihai
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Jérémie Vovelle
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Patrick Manckoundia
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France; Institut National de la Santé et de la Recherche Médicale U1093 Cognition Action Plasticité, Université de Bourgogne Franche-Comté, Dijon, Bourgogne Franche-Comté, France
| | - Alain Putot
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France.
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Perin M, De Panfilis L. Among equity and dignity: an argument-based review of European ethical guidelines under COVID-19. BMC Med Ethics 2021; 22:36. [PMID: 33789633 PMCID: PMC8011067 DOI: 10.1186/s12910-021-00603-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/22/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Under COVID-19 pandemic, many organizations developed guidelines to deal with the ethical aspects of resources allocation. This study describes the results of an argument-based review of ethical guidelines developed at the European level. It aims to increase knowledge and awareness about the moral relevance of the outbreak, especially as regards the balance of equity and dignity in clinical practice and patient's care. METHOD According to the argument-based review framework, we started our research from the following two questions: what are the ethical principles adopted by the ethical guidelines produced at the beginning of the COVID-19 outbreak related to resource allocation? And what are the practical consequences in terms of 'priority' of access, access criteria, management of the decision-making process and patient care? RESULTS Twenty-two ethical guidelines met our inclusion criteria and the results of our analysis are organized into 4 ethical concepts and related arguments: the equity principle and emerging ethical theories; triage criteria; respecting patient's dignity, and decision making and quality of care. CONCLUSION Further studies can investigate the practical consequences of the application of the guidelines described, in terms of quality of care and health care professionals' moral distress.
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Affiliation(s)
- Marta Perin
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
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Escher M, Nendaz M, Scherer F, Cullati S, Perneger T. Physicians' predictions of long-term survival and functional outcomes do not influence the decision to admit patients with advanced disease to intensive care: A prospective study. Palliat Med 2021; 35:161-168. [PMID: 33063607 DOI: 10.1177/0269216320963931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Long-term survival and functional outcomes should influence admission decisions to intensive care, especially for patients with advanced disease. AIM To determine whether physicians' predictions of long-term prognosis influenced admission decisions for patients with and without advanced disease. DESIGN A prospective study was conducted. Physicians estimated patient survival with intensive care and with care on the ward, and the probability of 4 long-term outcomes: leaving hospital alive, survival at 6 months, recovery of functional status, and recovery of cognitive status. Patient mortality at 28 days was recorded. We built multivariate logistic regression models using admission to the intensive care unit (ICU) as the dependent variable. SETTING/PARTICIPANTS ICU consultations for medical inpatients at a Swiss tertiary care hospital were included. RESULTS Of 201 evaluated patients, 105 (52.2%) had an advanced disease and 140 (69.7%) were admitted to the ICU. The probability of admission was strongly associated with the expected short-term survival benefit for patients with or without advanced disease. In contrast, the predicted likelihood that the patient would leave the hospital alive, would be alive 6 months later, would recover functional status, and would recover initial cognitive capacity was not associated with the decision to admit a patient to the ICU. Even for patients with advanced disease, none of these estimated outcomes influenced the admission decision. CONCLUSIONS ICU admissions of patients with advanced disease were determined by short-term survival benefit, and not by long-term prognosis. Advance care planning and developing decision-aid tools for triage could help limit potentially inappropriate admissions to intensive care.
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Affiliation(s)
- Monica Escher
- Division of Palliative Medicine, Geneva University Hospitals, Geneva, Switzerland.,Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Fabienne Scherer
- Division of Palliative Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphane Cullati
- Division of Palliative Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
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Escher M, Ricou B, Nendaz M, Scherer F, Cullati S, Hudelson P, Perneger T. ICU physicians' and internists' survival predictions for patients evaluated for admission to the intensive care unit. Ann Intensive Care 2018; 8:108. [PMID: 30430269 PMCID: PMC6236006 DOI: 10.1186/s13613-018-0456-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/09/2018] [Indexed: 11/29/2022] Open
Abstract
Background A higher chance of survival is a key justification for admission to the intensive care unit (ICU). This implies that physicians should be able to accurately estimate a patient’s prognosis, whether cared for on the ward or in the ICU. We aimed to determine whether physicians’ survival predictions correlate with the admission decisions and with patients’ observed survival. Consecutive ICU consultations for internal medicine patients were included. The ICU physician and the internist were asked to predict patient survival with intensive care and with care on the ward using 5 categories of probabilities (< 10%, 10–40%, 41–60%, 61–90%, > 90%). Patient mortality at 28 days was recorded. Results Thirty ICU physicians and 97 internists assessed 201 patients for intensive care. Among the patients, 140 (69.7%) were admitted to the ICU. Fifty-eight (28.9%) died within 28 days. Admission to intensive care was associated with predicted survival gain in the ICU, particularly for survival estimates made by ICU physicians. Observed survival was associated with predicted survival, for both groups of physicians. The discrimination of the predictions for survival with intensive care, measured by the area under the ROC curve, was 0.63 for ICU physicians and 0.76 for internists; for survival on the ward the areas under the ROC curves were 0.69 and 0.74, respectively. Conclusions Physicians are able to predict survival probabilities when they assess patients for intensive care, albeit imperfectly. Internists are more accurate than ICU physicians. However, ICU physicians’ estimates more strongly influence the admission decision. Closer collaboration between ICU physicians and internists is needed. Electronic supplementary material The online version of this article (10.1186/s13613-018-0456-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland. .,Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Bara Ricou
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Fabienne Scherer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - Stéphane Cullati
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - Patricia Hudelson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
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15
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Escher M, Cullati S, Hudelson P, Nendaz M, Ricou B, Perneger T, Dayer P. Admission to intensive care: A qualitative study of triage and its determinants. Health Serv Res 2018; 54:474-483. [PMID: 30362106 DOI: 10.1111/1475-6773.13076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine physicians' decision making and its determinants about admission to intensive care. DATA SOURCES/STUDY SETTING ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital. STUDY DESIGN We conducted in-depth interviews. DATA COLLECTION/EXTRACTION METHODS Interviews were analyzed using an inductive thematic approach. PRINCIPAL FINDINGS Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. CONCLUSIONS Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.,Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Patricia Hudelson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Bara Ricou
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
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