December 27, 2011 — A survey of intensive care unit (ICU) physicians and nurses in Europe and Israel reveals that these clinicians often perceive that they are providing inappropriate care, most often "too much care," to patients admitted to ICUs, according to a report published in the December 28 issue of JAMA.
According to the report, this perception of providing inappropriate care can lead to moral distress among clinicians, who may eventually decide to leave their jobs, further jeopardizing care of future patients. More than half of the respondents in this survey "were not confident that these situations would be resolved in the near future."
Researchers led by Ruth D. Piers, MD, from Ghent University Hospital in Belgium, conducted surveys at 82 ICUs. Of the 1651 survey respondents, 439 (27%) reported perceived inappropriate care for at least 1 patient during a 24-hour period, for a total 445 inappropriate care incidents. In 89% of those incidents, clinicians attributed "too much care" as the reason, and insufficient care in 11%. In other cases, they cited "distributive injustice," meaning other patients could have been better served under the specific circumstances.
The respondents defined inappropriate care as care that clinicians view as contradictory to their own personal beliefs and professional knowledge.
"Although the report by Piers et al provides a hazy lens through which to view appropriateness of care, it yields more clarity than prior studies," writes Scott D. Halpern, MD, PhD, from the University of Pennsylvania School of Medicine in Philadelphia, in an accompanying editorial. The report may turn out to be "the clarion call needed to spur more rigorous study of what happens to clinicians and the care they provide," he writes.
The researchers conducted the surveys in Europe on May 11 to 12, 2010, and in Israel on May 25, 2010. They used 3 types of questionnaires: 1 collecting characteristics of each ICU, such as mortality rate and number of clinicians; 1 collecting personal characteristics of clinicians, such as age, role, and job strain; and 1 collecting details about perceived inappropriateness of care.
The researchers suggest that interventions to improve communication and collaboration, relieve work overloads, and give clinicians more autonomy in decision-making could improve the overall picture. "[P]erceived inappropriateness of care was less common in ICUs in which physicians and nurses had a degree of job autonomy, an acceptable workload, and a high level of interdisciplinary collaboration and decision making," they add.
The survey gave clinicians 7 possible reasons to choose for inappropriate care:
- disproportion between amount of care and expected outcome,
- persistent nonadherence of the patient,
- other patients would benefit more from ICU care,
- inaccurate information was given to patient or family,
- patient's wishes concerning treatment were known but not respected,
- 1 party involved did not participate in treatment decision, and
- patient was not getting good-quality care.
Dr. Piers and colleagues report receipt of a grant from the European Society of Intensive Care Medicine/European Critical Care Research Network. One coauthor reports board membership, consultancy, grants received or pending, and speakers bureau participation with Gilead, Pfizer, and Merck, Sharp, & Dohme. Another coauthor reports receipt of meeting expenses from the European Society of Clinical Microbiology and Infectious Diseases, as well as other research grants from Astra-Zeneca, Bayer, Pfizer, General Electric, and Merck, Sharp, & Dohme. One coauthor reports receipt of consultancy fees from Abbott Laboratories, and one coauthor reports receipt of a grant or a pending grant from Pfizer. The remaining authors have disclosed no relevant financial relationships.
JAMA. 2011;306:2694-2703, 2725-2726.
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