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Inappropriate Care in European ICUs: Confronting Views From Nurses and Junior and Senior Physicians.
Piers, Ruth D. MD, PhD; Azoulay, Elie MD, PhD; Ricou, Bara MD; Ganz, Freda DeKeyser RN, PhD; Max, Adeline MD; Michalsen, Andrej MD, MPH; Maia, Paulo Azevedo MD; Owczuk, Radoslaw MD, PhD; Rubulotta, Francesca MD, PhD; Meert, Anne-Pascale MD; Reyners, Anna K. MD, PhD; Decruyenaere, Johan MD, PhD; Benoit, Dominique D. MD, PhD; for the Appropricus Study Group of the Ethics Section of the European Society of Intensive Care Medicine
[Miscellaneous] Chest. 146(2):267-275, August 6, 2014.

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BACKGROUND: ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power.

METHODS: We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations.

RESULTS: By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups.

CONCLUSIONS: ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.