What are the characteristics that lead physicians to perceive an ICU stay as non-beneficial for the patient?

Abstract

Purpose We sought to describe the characteristics that lead physicians to perceive a stay in the intensive care unit (ICU) as being non-beneficial for the patient. Materials and methods In the first step, we used a multidisciplinary focus group to define the characteristics that lead physicians to consider a stay in the ICU as non-beneficial for the patient. In the second step, we assessed the proportion of admissions that would be perceived by the ICU physicians as non-beneficial for the patient according to our focus group’s definition, in a large population of ICU admissions in 4 French ICUs over a period of 4 months. Results Among 1075 patients admitted to participating ICUs during the study period, 155 stays were considered non-beneficial for the patient, yielding a frequency of 14.4% [95% confidence interval (CI) 8.9, 19.9]. Average age of these patients was 72 ±12.8 years. Mortality was 43.2% in-ICU [95%CI 35.4, 51.0], 55% [95%CI 47.2, 62.8] in-hospital. The criteria retained by the focus group to define a non-beneficial ICU stay were: patient refusal of ICU care (23.2% [95%CI 16.5, 29.8]), and referring physician’s desire not to have the patient admitted (11.6% [95%CI 6.6, 16.6]). The characteristics that led physicians to perceive the stay as non-beneficial were: patient’s age (36.8% [95%CI 29.2, 44.4]), unlikelihood of recovering autonomy (61.9% [95%CI 54.3, 69.6]), prior poor quality of life (60% [95%CI 52.3, 67.7]), terminal status of chronic disease (56.1% [95%CI 48.3, 63.9]), and all therapeutic options have been exhausted (35.5% [95%CI 27.9, 43.0]). Factors that explained admission to the ICU of patients whose stay was subsequently judged to be non-beneficial included: lack of knowledge of patient’s wishes (52% [95%CI 44.1, 59.9]); decisional incapacity (sedation) (69.7% [95%CI 62.5, 76.9]); inability to contact family (34% [95%CI 26.5, 41.5]); pressure to admit (from family or other physicians) (50.3% [95%CI 42.4, 58.2]). Conclusions Non-beneficial ICU stays are frequent. ICU admissions need to be anticipated, so that patients who would yield greater benefit from other care pathways can be correctly oriented in a timely manner.

Anticipating need for intensive care in the healthcare trajectory of patients with chronic disease: A qualitative study among specialists

“…Indeed, the ICU physician is then in the awkward position of choosing between loss-of-opportunity for the patient if admission is refused, or alternatively, delivery of care that may later be deemed disproportionately burdensome [ 40 , 41 ] or even futile [ 42 ]. This can result in ICU admissions that are judged to have been non-beneficial [ 25 ]. The findings of this study plead in favour of enhanced collaboration between intensivists and referring specialists when there is debate about a potential ICU admission, especially if the question is being considered before any acute organ failure has occurred [ 43 , 44 ].…”

“…It is incumbent on ICU physicians to offer care that will provide the patient with a level of therapeutic engagement commensurate with that patient’s healthcare goals, personal desires and values, and with an acceptable anticipated quality of life after discharge from the ICU [ 22 , 23 ]. However, this balance can be difficult to achieve, especially in emergency situations, with a trade-off often occurring between the risk of loss of opportunity if ICU admission is refused, and the risk of unreasonable therapeutic obstinacy if the patient’s stay in the ICU is ultimately non-beneficial [ 24 , 25 ].…”

Non-readmission decisions in the intensive care unit: A qualitative study of physicians’ experience in a multicentre French study

“…A recent prospective, multicentre centre study in France that included 1075 patients [ 30 ] found that 14.4% of admissions to the ICU were felt to be inappropriate by the ICU physicians. The fact that ICU care or an ICU stay could be considered inappropriate should prompt us to think about ways to limit, or even avoid such situations, which can have nothing but negative consequences for the patient, the family and the healthcare professionals.…”

Non-beneficial admission to the intensive care unit: A nationwide survey of practices

“…The 4 domains addressed by the questionnaire, as well as the individual questions in each domain were developed based on a focus group of 10 physicians from university and non-academic hospitals, according to the methodology previously described elsewhere [ 12 ]. Briefly, 1 clinician (JPQ) and 1 sociologist (NMB) led the focus group discussions using open-ended questions to prompt the participants to envisage all the aspects that contribute to an ICU stay being considered as inappropriate or non-beneficial.…”

“…In one North-American study, 31% of patients who died in hospital were admitted to the ICU, despite the fact that they had clearly expressed a desire to receive comfort care only, and among these, 14% had received one or more life-sustaining therapies [ 11 ]. Recently, a prospective, multicentre study from France involving 4 centres showed that up to 22% of ICU stays could be deemed “non-beneficial” [ 12 ]. The authors showed that in approximately one quarter of “non-beneficial” ICU admissions, the patient had not wanted to be admitted to the ICU.…”