Perceived Inappropriateness of Intensive Care Treatment Among Clinicians: A Cross-Sectional Nationwide Survey on the Prevalence, Associated Factors, and Outcomes.

OBJECTIVES

To evaluate the prevalence and reasons for perceived inappropriateness of care (PIC) among ICU clinicians, to identify organizational, clinician, and work-related characteristics associated with PIC, and to determine if PIC is associated with adverse patient outcomes within 6 months post-ICU.

DESIGN

Single-day cross-sectional survey, supplemented with follow-up data.

SETTING AND PATIENTS: Physicians and nurses from 47 Dutch ICUs and 525 patients who were treated in the ICU on the survey day.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN

RESULTS

PIC (i.e., a patient situation in which care provision conflicts with a clinician's personal values or professional judgment) and other relevant variables were collected through questionnaires and the National Intensive Care Evaluation registry. A total of 1058 physicians and nurses (response rate, 72%) and 215 of the 397 eligible patients (54.2%) completed the survey. Among clinicians, 276 (26%) reported PIC for at least one patient. Clinicians mostly referred to distributive injustice ( n = 181; 70%) and disproportionality of care (66%). Being a nurse (adjusted odds ratio [aOR], 1.78; 95% CI, 1.37-2.33; p < 0.001) and working in a culture that avoids end-of-life decisions (aOR, 1.92; 95% CI, 1.51-2.45; p < 0.001) were associated with higher PIC risk. Larger ICU bed capacity (aOR, 0.97; 95% CI, 0.94-0.99; p = 0.004) and mutual respect within interdisciplinary teams (aOR, 0.84; 95% CI, 0.70-1.00; p = 0.045) were protective. PIC reported by multiple clinicians was independently associated with increased risk of death (aOR, 3.86; 95% CI, 1.23-12.16; p = 0.02) and the combined outcome (i.e., death, severely frail, or not living at home anymore; aOR, 2.91; 95% CI, 1.14-7.42; p = 0.03).

CONCLUSIONS

PIC is common in the ICU, inversely associated with a supportive ethical work environment, and should be regarded as a legitimate concern that warrants team reflection, as it is a prognostic marker of poor patient outcomes.