Physicians’ perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study

Abstract

ObjectiveThe 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.DesignThis 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.SettingData were collected in a Swiss tertiary care centre between March and June 2013.Participants12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions.ResultsPhysicians 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.ConclusionsIn 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.

Physicians' perceptions of intensive care patients' 1‐year prognoses compared to realistic prognoses

“…7 Team-based, collaborative decision-making has been suggested as a solution to ease the difficulty of deciding about intensive care when the risk of futility is high. 14 In our study, the median of the physicians' estimates was close to the realistic prognosis in the majority of cases, which could be interpreted that a group of physicians is wiser than many of its members. However, we did actually not study the estimating ability of groups, as each respondent answered the survey independently.…”

“…Seniority and collaborative decision-making are associated with withholding ICU care. 13,14 Some authors have concluded that senior doctors may have a better ability to identify patients who are too sick to benefit from ICU admission. 10 However, we did not find a significant difference between the most experienced doctors and the less F I G U R E 1 Distribution of the survey respondents' estimates of the probability of 1-year survival of intensive care patients.…”

“…However, short-term prognosis and several other factors weigh more in the decision-making than the longer-term prognosis. 14 Previous systematic reviews of the ICU triage have identified dozens 15 or even 200 16 criteria that affect ICU triage, which reflects the complexity of intensive care decisionmaking.…”

“…Seniority and collaborative decision‐making are associated with withholding ICU care 13,14 . Some authors have concluded that senior doctors may have a better ability to identify patients who are too sick to benefit from ICU admission 10 .…”

“…The variability in estimates of long‐term survival probability that we observed in this study could be one factor contributing to varying admission practices. However, short‐term prognosis and several other factors weigh more in the decision‐making than the longer‐term prognosis 14 . Previous systematic reviews of the ICU triage have identified dozens 15 or even 200 16 criteria that affect ICU triage, which reflects the complexity of intensive care decision‐making.…”