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Original Research: Critical Care |

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

Ruth D. Piers, MD, PhD; Elie Azoulay, MD, PhD; Bara Ricou, MD; Freda DeKeyser Ganz, RN, PhD; Adeline Max, MD; Andrej Michalsen, MD, MPH; Paulo Azevedo Maia, MD; Radoslaw Owczuk, MD, PhD; Francesca Rubulotta, MD, PhD; Anne-Pascale Meert, MD; Anna K. Reyners, MD, PhD; Johan Decruyenaere, MD, PhD; Dominique D. Benoit, MD, PhD; for the Appropricus Study Group of the Ethics Section of the European Society of Intensive Care Medicine
Author and Funding Information

From the Department of Geriatrics (Dr Piers) and the Department of Intensive Care Medicine (Drs Decruyenaere and Benoit), Ghent University Hospital, Ghent, Belgium; Medical ICU (Drs Azoulay and Max), Hôpital Saint-Louis and University Paris-7, Paris, France; the Department of Intensive Care (Dr Ricou), University Hospitals and University of Geneva, Geneva, Switzerland; School of Nursing (Dr DeKeyser Ganz), Hadassah-Hebrew University, Jerusalem, Israel; the Department of Anaesthesiology and Critical Care Medicine (Dr Michalsen), Tettnang Hospital, Tettnang, Germany; Serviço Cuidados Intensivos 1 (Dr Azevedo Maia), Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal; the Department of Anaesthesiology and Intensive Therapy (Dr Owczuk), Medical University of Gdansk, Gdansk, Poland; Imperial College NHS Trust (Dr Rubulotta), Centre for Perioperative Medicine and Critical Care Research, Charing Cross Hospital, London, England; Service des Soins Intensifs Medico-Chirurgicaux et Oncologie Thoracique (Dr Meert), Institut Jules Bordet, Brussels, Belgium; and the Department of Medical Oncology (Dr Reyners), University Medical Center Groningen, Groningen, The Netherlands.

CORRESPONDENCE TO: Ruth D. Piers, MD, PhD, Ghent University Hospital, Department of Geriatrics, De Pintelaan 185, 9000 Ghent, Belgium; e-mail: ruth.piers@ugent.be


These data were presented at the 12th European Association for Palliative Care Congress, May 18-21, 2011, Lisbon, Portugal, and at the 24th European Society of Intensive Care Medicine Annual Congress, October 1-5, 2011, Berlin, Germany.

FUNDING/SUPPORT: This study was supported by a European Society of Intensive Care Medicine/European Critical Care Research Network award (iMDsoft Patient Safety Research Award, 10,000 €, Vienna 2009).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(2):267-275. doi:10.1378/chest.14-0256
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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.


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