Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices.

Jean-Philippe Rigaud,Nicolas Meunier-Beillard,Auguste Dargent,Antoine Marchalot,Mikhael Giabicani,Jean-Pierre Quenot,Fiona Ecarnot,Marion Beuzelin

doi:10.1371/journal.pone.0205689

Abstract

PurposeWe investigated, using a multicentre survey of practices in France, the practices of ICU physicians concerning the decision not to readmit to the ICU, in light of current legislation.Materials and methodsMulticentre survey of practices among French ICU physicians via electronic questionnaire in January 2016. Questions related to respondents’ practices regarding re-admission of patients to the ICU and how these decisions were made. Criteria were evaluated by the health care professionals as regards importance for non-readmission.ResultsIn total, 167 physicians agreed to participate, of whom 165 (99%) actually returned a completed questionnaire from 58 ICUs. Forty-five percent were aged <35 years, 74% were full-time physicians. The findings show that decisions for non-readmission are taken at the end of the patient’s stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient’s medical file. While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework.ConclusionThis study shows that decisions not to re-admit a patient to the ICU need to be formally materialized, and anticipated by involving the patient and family in the discussions, as well as the other healthcare providers that usually care for the patient. The optimal time to undertake these conversations is likely best decided on a case-by-case basis according to each patient’s individual characteristics.

Highlights

Decisions to limit or withdraw treatment in the intensive care unit (ICU) usually concern patients in whom every possible curative therapeutic option has been attempted, and/or in whom pursuing treatment would be unreasonable in view of their current clinical state and likely outcome [1,2,3]
The findings show that decisions for non-readmission are taken at the end of the patient’s stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient’s medical file
While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework

Summary

Introduction

Decisions to limit or withdraw treatment in the intensive care unit (ICU) usually concern patients in whom every possible curative therapeutic option has been attempted, and/or in whom pursuing treatment would be unreasonable in view of their current clinical state and likely outcome [1,2,3]. In France, as in numerous other countries [3], decisions to limit or withdraw treatment are made within a strict legislative framework that involves a collegial decision-making procedure [4]. The collegial procedure must take into account the patients’ wishes, if they are known or have been recorded. When the patient’s wishes are not documented, the opinion of the family and/or surrogate must be sought. Once a decision has been reached, life-sustaining therapies are limited or withdrawn in conditions that have previously been evaluated [6, 7], and the patient can be oriented towards palliative care [4, 5]

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