Perceived Inappropriateness of Intensive Care Treatment Among Clinicians: A Cross-Sectional Nationwide Survey on the...

To evaluate the prevalence and reasons for perceived inappropriateness of care (PIC) among ICU clinicians, to identify organizational, clinician, and work-related characteristics associated with PIC, and to determine if PIC is associated with adverse patient outcomes within 6 months post-ICU.

Single-day cross-sectional survey, supplemented with follow-up data.

Physicians and nurses from 47 Dutch ICUs and 525 patients who were treated in the ICU on the survey day.

None.

PIC (i.e., a patient situation in which care provision conflicts with a clinician's personal values or professional judgment) and other relevant variables were collected through questionnaires and the National Intensive Care Evaluation registry. A total of 1058 physicians and nurses (response rate, 72%) and 215 of the 397 eligible patients (54.2%) completed the survey. Among clinicians, 276 (26%) reported PIC for at least one patient. Clinicians mostly referred to distributive injustice ( n = 181; 70%) and disproportionality of care (66%). Being a nurse (adjusted odds ratio [aOR], 1.78; 95% CI, 1.37-2.33; p < 0.001) and working in a culture that avoids end-of-life decisions (aOR, 1.92; 95% CI, 1.51-2.45; p < 0.001) were associated with higher PIC risk. Larger ICU bed capacity (aOR, 0.97; 95% CI, 0.94-0.99; p = 0.004) and mutual respect within interdisciplinary teams (aOR, 0.84; 95% CI, 0.70-1.00; p = 0.045) were protective. PIC reported by multiple clinicians was independently associated with increased risk of death (aOR, 3.86; 95% CI, 1.23-12.16; p = 0.02) and the combined outcome (i.e., death, severely frail, or not living at home anymore; aOR, 2.91; 95% CI, 1.14-7.42; p = 0.03).

PIC is common in the ICU, inversely associated with a supportive ethical work environment, and should be regarded as a legitimate concern that warrants team reflection, as it is a prognostic marker of poor patient outcomes.