Ruth Piers

Causes and consequences of disproportionate care in intensive care medicine.

Purpose of reviewIncreased use of advanced life-sustaining measures in patients with poor long-term expectations secondary to more chronic organ dysfunctions, comorbidities and/or a poor quality of life has become a worrying trend over the last decade. This can lead to futile, disproportionate or inappropriate care in the ICU. This review summarizes the causes and consequences of disproportionate care in the ICU. Recent findingsDisproportionate care seems to be common in European and North American ICUs. The initiation and prolongation of disproportionate care can be related to hospital facilities, healthcare providers, the patient and his/her representatives and society. This can have serious consequences for patients, their relatives, physicians, nurses and society. SummaryDisproportionate care is common in western ICUs. It can lead to violation of basic bioethical principles, suffering of patients and relatives and compassion fatigue and moral distress in healthcare providers. Avoiding inappropriate use of ICU resources and disproportionate care in the ICU should have high priority for ICU managers but also for every healthcare provider taking care of patients at the bedside.

Inappropriate Care in European ICUs: Confronting Views From Nurses and Junior and Senior Physicians

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.

Original ResearchCritical CareInappropriate Care in European ICUs: Confronting Views From Nurses and Junior and Senior Physicians

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.

Comparing Palliative Care in Care Homes Across Europe (PACE): Protocol of a Cross-sectional Study of Deceased Residents in 6 EU Countries

OBJECTIVES Although a growing number of older people are dying in care homes, palliative care has developed in these settings only recently. Cross-country representative comparative research hardly exists in this area. As part of a large EU-funded project, we aim to undertake representative comparative research in care homes in Europe, to describe and compare 6 countries in terms of (1) resident outcomes, quality and costs of palliative and end-of-life care; and (2) palliative care structures and staff knowledge and attitudes toward palliative care. We also aim to explore country, facility, staff, patient, and care characteristics related to better outcomes at resident level. DESIGN AND METHODS To obtain a representative nationwide sample, we will conduct a large-scale cross-sectional study of deceased residents in care homes in Belgium, Finland, Italy, the Netherlands, Poland, and the United Kingdom, using proportional stratified random sampling (taking into account region, facility type and bed capacity). In each country, all participating care homes retrospectively report all deaths of residents in and outside the facilities over the previous 3-month period. For each case, structured questionnaires, including validated instruments, are sent to (1) the administrator/manager, (2) staff member most involved in care, (3) treating physician (general practitioner or elderly care physician), and (4) a closely involved relative. It is estimated that, per country, 50 care homes are needed on average to obtain a minimum of 200 deceased residents. Collected data include clinical and sociodemographic characteristics, quality of dying, quality and costs of palliative care and end-of-life care, and palliative care structures at the facility level and country level. To obtain a representative view of staff knowledge and attitudes regarding palliative care, PACE will conduct a cross-sectional study of staff working in the participating care homes. CONCLUSION Considering the growing challenges associated with aging in all European countries, there is an urgent need to build a robust international comparative evidence base that can inform the development of policies to target improved palliative care in care homes. By describing this research protocol, we hope to inform international research in care homes on how to perform representative end-of-life care research in these settings and better understand which systems are associated with better outcomes.

Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool

Background Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU). Objectives To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates. Methods Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups. Results Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner. Conclusions The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians’ behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.

Critically ill octogenarians and nonagenarians : evaluation of long-term outcomes, post-hospital trajectories and quality of life one year and seven years after ICU discharge

BACKGROUND The aim of this study was to investigate long-term outcomes, posthospital trajectories, and quality of life (QOL) in patients ≥80 years admitted to the Intensive Care Unit (ICU) of a tertiary care hospital. METHODS A 1-year prospective observational cohort analysis was performed. All consecutive patients ≥80 years admitted to the ICU were screened for inclusion. Demographics, comorbidity, organ failures, and outcomes were analyzed. QOL before admission, 3 months, 1 year, and 7 years after ICU discharge was assessed using EuroQoL-5D (EQ-5D) and Medical Outcomes Study 36-item Short Form Health Survey (SF-36) questionnaires. Statistical significance was attained at P<0.05. RESULTS In the study 131 patients with a median age of 83 years (IQR 81-85), a Charlson Comorbidity Index of 2 (IQR 0-4), a SOFA Score of 4 (3-8) upon ICU admission and an APACHE II Score of 20 (IQR 15-24) were included. ICU, hospital, 3 months, 1-year, and 7-year mortality rates were 17%, 29%, 39%, 50%, and 84% respectively. QOL decreased significantly over time. Most elderly considered QOL as acceptable and perceived only a worsening in physical functioning and self-care at long-term. Of the 1-year and 7-year survivors, 21% and 39% (P=0.122) lived in nursing homes, and 81% and 72% (P=0.423) preferred to be readmitted to an ICU department if necessarily. CONCLUSIONS Most critically ill long-term elderly survivors lived at home, perceived their QOL as acceptable, and wanted to be readmitted to the ICU if necessary. In older patients, age alone is a poor indicator of the possible value to be gained from an ICU admission.

Integrating palliative care in long-term care facilities across Europe (PACE): protocol of a cluster randomized controlled trial of the ‘PACE Steps to Success’ intervention in seven countries

BackgroundSeveral studies have highlighted the need for improvement in palliative care delivered to older people long-term care facilities. However, the available evidence on how to improve palliative care in these settings is weak, especially in Europe. We describe the protocol of the PACE trial aimed to 1) evaluate the effectiveness and cost-effectiveness of the ‘PACE Steps to Success’ palliative care intervention for older people in long-term care facilities, and 2) assess the implementation process and identify facilitators and barriers for implementation in different countries.MethodsWe will conduct a multi-facility cluster randomised controlled trial in Belgium, Finland, Italy, the Netherlands, Poland, Switzerland and England. In total, 72 facilities will be randomized to receive the ‘Pace Steps to Success intervention’ or to ‘care as usual’. Primary outcome at resident level: quality of dying (CAD-EOLD); and at staff level: staff knowledge of palliative care (Palliative Care Survey). Secondary outcomes: resident’s quality of end-of-life care, staff self-efficacy, self-perceived educational needs, and opinions on palliative care. Economic outcomes: direct costs and quality-adjusted life years (QALYs).Measurements are performed at baseline and after the intervention. For the resident-level outcomes, facilities report all deaths of residents in and outside the facilities over a previous four-month period and structured questionnaires are sent to (1) the administrator, (2) staff member most involved in care (3) treating general practitioner, and (4) a relative. For the staff-level outcomes, all staff who are working in the facilities are asked to complete a structured questionnaire. A process evaluation will run alongside the effectiveness evaluation in the intervention group using the RE-AIM framework.DiscussionThe lack of high quality trials in palliative care has been recognized throughout the field of palliative care research. This cross-national cluster RCT designed to evaluate the impact of the palliative care intervention for long-term care facilities ‘PACE Steps to Success’ in seven countries, will provide important evidence concerning the effectiveness as well as the preconditions for optimal implementation of palliative care in nursing homes, and this within different health care systems.Trial registrationThe study is registered at www.isrctn.com – ISRCTN14741671 (FP7-HEALTH-2013-INNOVATION-1 603111) Registration date: July 30, 2015.

Validation of the Supportive and Palliative Care Indicators Tool in a Geriatric Population

BACKGROUND Timely identification of patients in need of palliative care is especially challenging in a geriatric population because of prognostic uncertainty. The Supportive and Palliative Care Indicators Tool (SPICT™) aims at facilitating this identification, yet has not been validated in a geriatric population. OBJECTIVE This study validates the SPICT in a geriatric patient population admitted to the hospital. DESIGN This is a retrospective cohort study. SETTING Subject were patients admitted to the acute geriatric ward of a Belgian university hospital between January 1 and June 30, 2014. MEASUREMENTS Data including demographics, functional status, comorbidities, treatment limitation decision (TLD), and one-year mortality were collected. SPICT was measured retrospectively by an independent assessor. RESULTS Out of 435 included patients, 54.7% had a positive SPICT, using a cut-off value of 2 for the general indicators and a cut-off value of 1 for the clinical questions. SPICT-positive patients were older (p = 0.033), more frequently male (p = 0.028), and had more comorbidities (p = 0.015) than SPICT-negative patients. The overall one-year mortality was 32.2%, 48.7% in SPICT-positive patients, and 11.5% in SPICT-negative patients (p < 0.001). SPICT predicted one-year mortality with a sensitivity of 0.841 and a specificity of 0.579. The area under the curve of the general indicators (0.758) and the clinical indicators of SPICT (0.748) did not differ (p = 0.638). In 71.4% of SPICT-positive cases, a TLD was present versus 26.9% in SPICT-negative cases (p < 0.001). CONCLUSION SPICT seems to be valuable for identifying geriatric patients in need of palliative care as it demonstrates significant association with one-year mortality and with clinical survival predictions of experienced geriatricians, as reflected by TLDs given.

A Typology of Interprofessional Teamwork in Acute Geriatric Care: A Study in 55 units in Belgium

To explore the quality of interprofessional teamwork in acute geriatric care and to build a model of team types.

Grief and loss in older people residing in nursing homes : (un)detected by nurses and care assistants?

AIM The aim of this study was to explore how nurses and care-assistants (nursing staff) working in six Flemish nursing homes experience and describe their involvement in grief care. BACKGROUND Although grief in older people is widely described in literature, less is known about how nursing staff in nursing homes offer and perceive grief care. DESIGN A qualitative research design with elements of constructivist grounded theory was used. METHODS Loosely structured face-to-face interviews were done with fourteen nurses and care-assistants. Data were collected from October 2013-March 2014. Interview transcripts were analysed using the Qualitative Analysis Guide of Leuven (QUAGOL) method with support of NVivo 10. FINDINGS Grief care in nursing homes is characterized by a complex tension between two care dimensions: (1) being involved while keeping an appropriate distance; and (2) being while doing. Nursing staff described key enablers and influencing factors for grief care at the level of both the individual and the organizational context. CONCLUSION Findings suggest an established personal sensitivity for grief care considered from the nursing staff points of view. Nevertheless, a common denominator was the necessity to further develop a supportive and multidisciplinary grief care policy ingrained in the existing care culture. Suggested components of this grief care policy are: (a) centring attention on non-death-related loss and the cumulative nature of loss in residents; (b) building capacity by means of reflective practices; and (c) the importance of self-care strategies for nursing staff. Furthermore, the findings from this study point towards a need for education and training.