Nonbeneficial admission to intensive care of palliative care patients: a qualitative study
M. Escher1, S. Cullati1, M. Nendaz1, P. Hudelson1 (1Genève)
Providing nonbeneficial intensive care treatment to patients with advanced disease prolongs suffering at the end of life. It is associated with family distress and healthcare staff burnout.
To determine whether physicians integrate potentially nonbeneficial treatments in their clinical reasoning for ICU admission decisions and how they resolve the question.
We conducted qualitative in-depth interviews with 12 ICU physicians and 12 internists working in the Geneva University Hospitals, a tertiary care hospital with 34 adult ICU beds. Interviews were analysed using an inductive approach to thematic content analysis.
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, i.e. 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 terminally ill patient for a limited amount of time in order to fulfill a personal need.
In situations of potentially nonbeneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Additional research should focus on how physicians weigh multiple contextual factors and how institutional guidelines and advance care planning can help admission decisions.
Funding: Swiss National Science Foundation, NRP 67 “End-of-life”