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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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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] [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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Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C, Slowther A. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.
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Affiliation(s)
- Chris Bassford
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicolas Krucien
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Agnieszka Ignatowicz
- Warwick Medical School, University of Warwick, Coventry, UK
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine Flowers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Gavin Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Quinton
- Warwick Medical School, University of Warwick, Coventry, UK
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Huayi Huang
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Turner
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike Brooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aimee McCreedy
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Caroline Blake
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Medical School, University of Warwick, Coventry, UK
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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] [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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Escher M, Perneger TV, Rudaz S, Dayer P, Perrier A. Impact of advance directives and a health care proxy on doctors' decisions: a randomized trial. J Pain Symptom Manage 2014; 47:1-11. [PMID: 23742734 DOI: 10.1016/j.jpainsymman.2013.03.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 03/02/2013] [Accepted: 03/19/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Advance directives or proxy designations are widely recommended, but how they affect doctors' decision making is not well known. OBJECTIVES The aim of this study was to quantify the influence of advance directives and proxy opinions on doctors' decisions. METHODS We mailed to all the generalists and internists in French-speaking Switzerland (N = 1962) three vignettes describing difficult decisions involving incapacitated patients. In each case, the advance directive requested that further care be withheld. One vignette tested the impact of a written advance directive vs. a proxy. Another compared the impact of a handwritten directive vs. a formalized document. The third vignette compared the impact of a family member vs. a doctor as a proxy. Each vignette was prepared in three or four versions, including a control version in which no directive or proxy was present. Vignettes were randomly allocated to respondents. We used logistic regression to predict the decision to forgo a medical intervention. RESULTS Compared with the control condition, the odds of forgoing a medical intervention were increased by the written advance directive (odds ratio [OR] 7.3; P < 0.001), the proxy (OR 7.9; P < 0.001), and the combination of the two (OR 35.7; P < 0.001). The handwritten directive had the same impact (OR 13.3) as the formalized directive (OR 13.8). The effect of proxy opinion was slightly stronger when provided by a doctor (OR 11.3) rather than by family (OR 7.8). CONCLUSION Advance directives and proxy opinions are equally effective in influencing doctors' decisions, but having both has the strongest effect. The format of the advance directive and the identity of the proxy have little influence on decisions.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland.
| | - Thomas V Perneger
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Sandrine Rudaz
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland
| | - Arnaud Perrier
- Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
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Transition from curative efforts to purely palliative care for neonates: does physiology matter? Adv Neonatal Care 2011; 11:216-22. [PMID: 21730916 DOI: 10.1097/anc.0b013e31821be411] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To isolate the threshold point in which the goal of care for an infant with life-limiting conditions transitions from curative efforts to purely palliative care. DESIGN Descriptive Web-based survey of 285 neonatal physicians and nurses who had participated in care of dying infants. METHOD Researcher-developed tool measured multiple palliative care concepts related to transition to purely palliative care, such as identification of infants for whom purely palliative care should be offered; physician and nurse satisfaction with and barriers to the transition process; physiological factors that indicated that the infant was ready for transition to purely palliative care; publication knowledge to guide palliative care; and factors influencing decision making. RESULTS The study aim was to identify the physiology involved in coming to the end of life and indicating a transition need for palliative care. But although the respondents were able to identify physiological factors or lethal conditions leading to a transition to purely palliative care, they stated that these factors were not how the goals of care were established. Respondents (96%) stated that parental agreement was the determinant to palliative care transition, and, regardless of neonatal physiological condition, without agreement, curative technological efforts continued. Respondents felt that more education on the palliative care process for both staff and families was necessary to move dignified end-of-life care forward. CONCLUSIONS Parents must be our partners when the burden of care to the infant is greater than the benefit. Suggestions to assist both parents and providers are offered. CLINICAL RELEVANCE Although this study is based on end-of-life decision making for newborns, the findings may resonate to nurses who care for dying patients of any age group, with any diagnosis, cared for in any type of medical-surgical or critical care unit. The findings describe the American concept of patient and family autonomy and problems that have arisen from the implementation of autonomy in end-of-life decision making regarding withholding/withdrawing therapies that provide artificial life support.
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Abstract
PURPOSE OF REVIEW The intensive care unit (ICU) provides continuous surveillance and specialized care to acutely ill patients. The decisions on patient admission and discharge should be based on common clinical criteria in order to guarantee equity. RECENT FINDINGS The survival benefit of early admission to intensive care has been demonstrated recently. Sometimes, the number of potential patients may exceed the available beds making triage of the patients necessary. The prioritization model based on the benefit that the patient can have from the admission is the most used. In the case of the outbreak peak of pandemic A H1N1 flu, a triage plan using Sequential Organ Failure Assessment score combined with inclusion and exclusion criteria to complement clinical judgment has been recommended. Nevertheless, studies have shown that this triage could lead to withdrawal of life support in patients who survive. Triage implies refusal of some patients, and refusal rates vary greatly even across the same country. Policies for discharge from intensive care show wide variability influenced by the availability of step-down facilities. SUMMARY The decisions to admit and discharge patients depend on patient, structure and physician-related variables. Early ICU admission of the critically ill patient is beneficial. Future analysis should also investigate economic parameters.
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