Chest. 2014 May 15. doi: 10.1378/chest.14-0256. [Epub ahead of print]

Inappropriate care in European Intensive Care Units: confronting views from nurses, junior and senior physicians.

Piers RD, Azoulay E, Ricou B, DeKeyser Ganz F, Max A, Michalsen A, Maia PA, Owczuk R, Rubulotta F, Meert AP, Reyners AK, Decruyenaere J, Benoit DD; for the Appropricus Study Group of the Ethics Section of the ESICM.

Abstract

IMPORTANCE:

Intensive Care Unit (ICU) care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aims to assess differences in - and reasons for - perceived inappropriate care across ICU care providers with varying levels of decision-making power.

METHODS:

Subsequent analysis from the Appropricus Study, a cross-sectional study on 11 May 2010 that included 1218 nurses, 180 junior, and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate perceived inappropriate care (PIC). The present study focuses on differences across healthcare providers regarding the reasons for continuing PIC in real patient situations.

RESULTS:

By multivariate analysis, nurses were found to have higher PIC rates compared to senior and junior physicians; but nurses and senior physicians were more distressed by perceived disproportionate care compared to junior physicians (33%, 25% and 9%, respectively; p=0.026). Perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians; and poor team and family communication, the fact that no one was taking initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians more frequently reported pressure from the referring physician as a reason compared to nurses and junior physicians. Family-related factors were reported by similar proportions of participants in the three groups.

CONCLUSIONS:

ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in reasons for PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians a lack of initiative and poor communication, while physicians more often ascribed prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improve moral distress and the quality of patient care.