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  • Physicians’ perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study

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Intensive care
Original research
Physicians’ perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study
  1. Monica Escher1,2,
  2. Mathieu R Nendaz2,3,
  3. Stéphane Cullati4,5,
  4. Patricia Hudelson6
  1. 1Division of Palliative Medicine, University Hospitals of Geneva, Geneva, Switzerland
  2. 2Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
  3. 3Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
  4. 4Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland
  5. 5Population Health Laboratory, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
  6. 6Department of Primary Care, University Hospitals of Geneva, Geneva, Switzerland
  1. Correspondence to Dr Monica Escher; monica.escher{at}hcuge.ch

Abstract

Objective The use of intensive care at the end of life can be high, leading to inappropriate healthcare utilisation, and prolonged suffering for patients and families. The objective of the study was to determine which factors influence physicians’ admission decisions in situations of potentially non-beneficial intensive care.

Design This is a secondary analysis of a qualitative study exploring the triage process. In-depth interviews were analysed using an inductive approach to thematic content analysis.

Setting Data were collected in a Swiss tertiary care centre between March and June 2013.

Participants 12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions.

Results Physicians struggled to understand the request for intensive care for patients with advanced disease and full code status. Physicians considered patients’ long-term vital and functional prognosis, but they also resorted to shortcuts, that is, a priori consensus about reasons for admitting a patient. Family pressure and unexpected critical events were determinants of admission to the ICU. Patient preferences, ICU physician’s expertise and collaborative decision making facilitated refusal. Physicians were willing to admit a patient with advanced disease for a limited amount of time to fulfil a personal need.

Conclusions In situations of potentially non-beneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Institutional guidelines and timely goals of care discussions with patients with advanced disease and their families could contribute to ensuring appropriate levels of care.

  • intensive & critical care
  • medical ethics
  • palliative care
  • qualitative research
  • quality in health care

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. No additional data are available.

https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjopen-2020-046268

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as online supplemental information. No additional data are available.

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    Footnotes

    • Contributors ME contributed to study concepts. ME, MRN, SC and PH contributed to study design. SC and ME collected the data. All the authors contributed to quality control of the data. All authors contributed to data analysis and interpretation. ME drafted the manuscript. All authors contributed to manuscript editing and review.

    • Funding This work was supported by the Swiss National Science Foundation, National Research Program ‘End of Life’ (NRP 67) grant number 139304.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.