Abstract
PurposeWe 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 methodsIn 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.ResultsAmong 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]).ConclusionsNon-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.
Highlights
In the daily routine practice of Intensive Care Unit (ICU) physicians, established criteria usually make it possible for admission decisions to be made unequivocally [1, 2]
Among 1075 patients admitted to participating intensive care unit (ICU) 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]
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])
Summary
In the daily routine practice of Intensive Care Unit (ICU) physicians, established criteria usually make it possible for admission decisions to be made unequivocally [1, 2]. The recommendations of the Society of Critical Care Medicine (SCCM) for ICU triage, admission, and discharge [1] suggest that some overtriage is acceptable, i.e. the understanding is that it will inevitably transpire that some patients who were admitted to the ICU could have been adequately treated via another care pathway without requiring ICU care. This type of situation may arise in particular when the ICU admission occurs in the context of an acute, unanticipated episode, where the patients’ wishes may be unknown, and/or the family are unavailable [3]. There is a compelling need for a qualitative evaluation of the patient-, and/or situation-related characteristics that lead clinicians to consider an ICU stay as being non-beneficial for a given patient
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