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Perceptions of the Appropriateness of Care in California Adult Intensive Care Units

Matthew Anstey, John Adams, and Elizabeth McGlynn

Researchers have found that patients often receive treatment in the ICU that neither matches their preferences nor is likely to benefit them.

A heart rate monitor readout.

In a 2012 study of Californians' attitudes about death and dying, 70% of respondents said that they would prefer to die at home, yet the majority still die in hospitals, often in the intensive care unit (ICU), where patients receive the highest intensity and most costly care. The mismatch between the treatment provided and patients' wishes or the likely benefits is especially pronounced in California, which ranks among the highest on the Dartmouth Atlas index of "hospital care intensity." And the statewide campaign Let's Get Healthy California has identified hospital deaths associated with ICU stays as a problem to be monitored.

To understand the frequency of and reasons for inappropriate care, researchers surveyed over 1,300 California ICU physicians and nurses about their experiences and perceptions. Some 91% of respondents were familiar with patients receiving inappropriate treatment.

The top three reasons why providers considered care to be inappropriate were overtreatment (93%), the amount of care was inconsistent with expected quality of life (86%), or the patient was dying and could be better managed elsewhere (84%). Most cases of inappropriate treatment were characterized by a patient who was not expected to improve (33%) or not expected to survive (50%) despite receiving treatment.

About half (51%) responded that they found such situations distressing, yet most (68%) did not believe they could change the situation. Instead, respondents rated possible solutions to reduce inappropriate ICU treatment. The greatest support was for formal communication training (90%) and for mandatory family meetings once a patient had been in the ICU for more than 72 hours (89%). Other possible solutions included using triggers at hospital admission to ensure advance directives are documented (84%), allow intensivists to control admission decisions and refusals to the ICU (81%), or offer a limited trial of ICU care for patients with multiple comorbidities or poor pre-morbid state (79%).

In a separate questionnaire, researchers found the perception of inappropriate treatment in the ICU was strongly correlated with an ICU culture that showed a lack of collaboration among doctors and nurses and a perception of patient death as failure. Also, although the availability of ethics services, inpatient palliative care, and team-based multidisciplinary rounds were high in these hospitals, these services by themselves did not eliminate the provision of inappropriate treatment.

The full article, supported by the California Health Care Foundation, is available at no charge on the Critical Care website.

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