Do we do too much ?
Dominique BENOIT, MD, PhD
Department of Intensive Care
Ghent University Hospital
Belgium
Introduction
Initial goal of ICM : treating previously healthy patients suffering from acute
organ dysfunction(s) until full or partial recovery
However, over the last decades there is an increasing referal of patients with
chronic underlying comorbidities or poor quality of life to the ICU together
with an increasing ICU use in the last month(s) of life
JM Teno JAMA 2013
Respectively 73% of European and 87% of Canadian critical care physicians
declare that they frequently admit patients with poor expectations
JL Vincent Crit care Med 1999
VA Palda J of Crit care 2005
≠ automatically futile ! But is it appropriate or disproportionate ?
E Kompanje Curr Opin Crit Care 2013
JT Bosslet E Am J Resp Crit Care 2015
Disproportionate care : definition
Care which is perceived by clinicians as
disproportionate (“too much” or “too little”) in
relation to the expected prognosis of the patient
in terms of expected survival or quality of life or
to the patients’ or relatives’ wishes.
Ethical principles
Beneficence
The clinicians’ duty to help patients (whenever possible)
Non-maleficence
The obligation to avoid harm
Respect for autonomy
The patients’ right for self-determination (within limits of modern medicine)
Distributive justice
Fair allocation of medical resourcers
Magnitude of the problem
– 27% (439/1651) of physicians and nurses found that care was inappropriate
≥ 1 patients / 93% “excessive care” / 23% (207/883 )of the patients
Piers et al JAMA 2011
– 38% (444/1169) of the clinicians (51% in physicians and 36% in nurses)
identified at least 1 patient receiving inappropriate treatment on the day
of survey (93% “excessive care”)
Anstey et al Crit Care 2013
– 6.1% (19/294) of the patients, however in 37.5% (110/294) of these
patients at some point during the treatment
Singal RK et al Can Respir J 2014
Prevalence of perceived inappropriate care
– 27% (439/1651) of physicians and nurses found that care
was inappropriate for at least one of their patients on the
day of the survey
– To what extend are you confident that inappropriate care in this
patient will be resolved in your ICU? (57% are not confident)
Very confident
10%
Quite confident
33%
Not so confident
37%
Not confident at all
20%
N= 377, Mi s s i ng = 68
– How often do similar situations occur in your ICU? (63% says often)
Seldom
6%
31%
Not so often
Quite often
47%
Very often
16%
N= 379, mis s ing = 66
Piers et al JAMA 2011
Excessive care : ICU-related factors
*
Financial advantage
Hospital hierarchy pressure
*
*
Statistical significant difference
between nurses and physicians
*
Not priority by an ICU member
Fear of ligitation
ICU Nurses
Not priority by majority of ICU team
ICU Physicians
No action despite consensus
*
No one takes initiative (laissez-faire)
Lack of consensus
*
Prognostic uncertainty
0%
10%
20%
30%
40%
50%
60%
70%
Piers et al, Chest 2014
Excessive care : factors related to communication
*
Within the ICU team
phys - phys
*
nurse - phys
phys - superior
headnurse - phys
ICU nurses
ICU physicians
nurse - nurse
*Statistical significant difference
nurse - headnurse
between nurses and physicians
*
To the family or patient
Between ICU team and referr phys
0%
5% 10% 15% 20% 25% 30% 35% 40% 45%
Piers et al, Chest 2014
DISPROPRICUS study
Pre-liminary results
Dominique BENOIT, MD, PhD
On behalf of the DISPROPRICUS study group
of the Ethics section of the ESICM
Objectives
1) to examine the incidence, time of onset and duration of (perceptions
of) disproportionate care and the accompanying degree of moral distress
among doctors and nurses in Europe and the US during a 28 days period
2) to assess whether perceptions of disproportionate care are
informative about the patient’s one year prognosis and in which
circumstances these perceptions are informative
3) to assess how the first two objectives are affected by the Ethicaldecision-making climate prevailing in the unit
Theoretical framework
Team leader
patient at t=0
Clinician
Theoretical framework
Ethical decision-making climate
3
decision making
Team leader
patient at t=0
1
(self)reflection
2
Clinician
communication
Ethical decision-making climate
Survey consisting of
11 validated questions purely focusing on EOL care
R. Piers JAMA 2011
+
24 validated questions focusing on preconditions to obtain a good ethical
decision-making climate ( interdisciplinary collaboration, respect & leadership)
Interprofessional Practice and Education Quality Tool
B. Vandenbulcke J of Interprof Care 2016
ICU Safety Attitude Questionnaire
JB Sexton BMC Health Serv Res 2006
Leader Behavior Description Questionnaire
RM Stogdill 1957
Theoretical framework
Team leader
patient at t=0
Clinician
moral distress
“disproportionate care”
intent to jobleave
Theoretical framework
Team leader
Triage decisions
EOL decisions
patient at t=0
patient at t+x
Clinician
moral distress
“disproportionate care”
intent to jobleave
Theoretical framework
Team leader
Triage decisions
EOL decisions
patient at t=0
1 year
outcome
patient at t+x
Clinician
moral distress
?
“disproportionate care”
intent to jobleave
Theoretical framework
Ethical decision-making climate
Team leader
Triage decisions
EOL decisions
patient at t=0
1 year
outcome
patient at t+x
Clinician
moral distress
?
“disproportionate care”
intent to jobleave
Overall
Ethical decision climate
Good
In my ICU…
Average
Poor
+
-
n=2992
n=535
n=1253
n=302
n=902
Patients with little chance of recovery are frequently admitted
70%
63%
64%
69%
82%
These patients frequently occupy an ICU bed
55%
52%
44%
51%
69%
EOL decisions are frequently postponed
48%
43%
40%
43%
66%
Death is perceived as a treatment failure
19%
14%
12%
18%
33%
We regularly reflect about the quality of care provided
52%
72%
52%
72%
35%
There is an open and informal dialogue
76%
84%
79%
79%
56%
There is structural and formal dialogue
63%
75%
66%
67%
44%
Discussions lead to greater understanding and agreements
53%
82%
62%
68%
38%
Nurses are involved in EOL decision making
55%
68%
70%
15%
40%
Nurses are present during EOL family meetings
73%
88%
93%
18%
55%
80% of explained variability related to chronic underlying disease !
COHESIS study
Study proposal
Dominique BENOIT, MD, PhD
Ghent University Hospital
Belgium
Objectives
1) to examine the incidence, time of onset and duration of (perceptions
of) excessive care and the accompanying degree of moral distress among
doctors and nurses taking care of critically ill patients (hematologic ward
and ICU)
2) to assess whether perceptions of disproportionate care are
informative about the patient’s one year prognosis and in which
circumstances these perceptions are informative
3) to assess how the first two objectives are affected by the Ethicaldecision-making climate prevailing in the unit
COHESIS
• Assess daily during the first 7 days of ICU
stay whether the care is :
–
–
–
–
Full code ICU management
ICU trial
Exceptional ICU admission
Nonbeneficial ICU admission
• Both sides
– Hematology team
– ICU team
Nonbeneficial
Exceptional
ICU trial
Full code
Perceptions on
the critically ill in the ICU
• If you judge the ICU admission as exceptional
or futile, please explain why you think the
patient is nonetheless receiving advanced life
support:
–
–
–
–
ICU related factors ...
Haematology related factors ...
Patient/family related factors ...
Communication/information issues
Nonbeneficial
Exceptional
ICU trial
Full code
Piers et al JAMA 2011 & Chest 2014
Time table
• April – May 2017:
– Reactivation of participating centers by Esther Van der
zee (and myselve)
• May- June 2017:
– Questionnaire translation (>>Danish)
– Testing of the website / questionnaire (Ghent)
• May-September 2017:
– Preparing the study website
– Ethical committee submission
Time table
• October 2017:
– Final debriefing at ESICM
– Center characteristics (local investigators)
• November 2017:
– Clinicians questionnaire (phase II)
• December 2017 – December 2018 (?) :
– Patient inclusions and daily perceptions (Phase
III)
– 750 to 1000 patients
Time table
• December 2018
– One year outcome and QOL
• January- September 2019
– Data analysis
Participating centers
• Belgium
– Ghent University Hospital
– Institut Jules Bordet, Brussels
– UCL, Brussels
• UK
– King’s College hospital London
• France
– Hôpital Saint-Louis Paris
– Hôpital Cochin Paris
– Paoli-calmette, Marseille
• The Netherlands
– UMCG, Groningen
– Erasmus, Rotterdam
– Radboud MC, Nijmegen
• Denmark
– Rigshospitalet Copenhagen
Thank you for your attention !
Any question left ?
[email protected]
[email protected]