Ruth D. Piers, MD, PhD; Elie Azoulay, MD, PhD; Bara Ricou, MD; Freda DeKeyser Ganz, RN, PhD; Adeline Max, MD; Andrej Michalsen, MD, MPH; Paulo Azevedo Maia, MD; Radoslaw Owczuk, MD, PhD; Francesca Rubulotta, MD, PhD; Anne-Pascale Meert, MD; Anna K. Reyners, MD, PhD; Johan Decruyenaere, MD, PhD; Dominique D. Benoit, MD, PhD; for the Appropricus Study Group of the Ethics Section of the European Society of Intensive Care Medicine CHEST Aug 2014; 146(2): 267-275
BACKGROUND: ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power.
METHODS: We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations.
RESULTS: By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A 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, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. 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 the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe 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 improving moral distress and the quality of patient care.
Nurses and physicians may feel that the level of care given to a patient is inappropriate or inconsistent with their professional knowledge or personal beliefs.1,2 ICU workers who provide care that they consider inappropriate may experience acute moral distress. If not acknowledged, this distress may result in overt conflicts3 or, worse, in indirect manifestations such as burnout,4‐6 depression,7 substance abuse,8 or a decision to change jobs.4,9‐11
Moral distress is highly prevalent in nurses because of their lack of decision-making authority.9,10,12,13 Junior physicians also have limited decision-making power and may feel that some decisions made by senior physicians are morally unacceptable.14‐16 Surprisingly, the Appropricus study showed that one-third of senior ICU physicians also reported instances of perceived inappropriate care, of which the most common type was excessive care.11 That physicians with decision-making power were troubled by perceptions of inappropriate care deserved further analysis.17
This report adds to the initial publication by looking in more detail at the differences among ICU care providers who have different levels of decision-making power, in the perceived inappropriate care. New in this study is that we separated the answers of junior physicians from those of senior physicians. Additionally, we assessed not only the frequency of perceived inappropriate care, but also the reasons for which the ICU staff members ascribed that perceived inappropriate care.
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