Abstract
Purpose
To assess physician decisions about ICU admission for life-sustaining treatments (LSTs).
Methods
Observational simulation study of physician decisions for patients aged ≥80 years. Each patient was allocated at random to four physicians who made decisions based on actual bed availability and existence of an additional bed before and after obtaining information on patient preferences. The simulations involved non-invasive ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of IMV (RRT after IMV).
Results
The physician participation rate was 100/217 (46 %); males without religious beliefs predominated, and median ICU experience was 9 years. Among participants, 85.7, 78, and 62 % felt that NIV, IMV, or RRT (after IMV) was warranted, respectively. By logistic regression analysis, factors associated with admission were age <85 years, self-sufficiency, and bed availability for NIV and IMV. Factors associated with IMV were previous ICU stay (OR 0.29, 95 % CI 0.13–0.65, p = 0.01) and cancer (OR 0.23, 95 % CI 0.10–0.52, p = 0.003), and factors associated with RRT (after IMV) were living spouse (OR 2.03, 95 % CI 1.04–3.97, p = 0.038) and respiratory disease (OR 0.42, 95 % CI 0.23–0.76, p = 0.004). Agreement among physicians was low for all LSTs. Knowledge of patient preferences changed physician decisions for 39.9, 56, and 57 % of patients who disagreed with the initial physician decisions for NIV, IMV, and RRT (after IMV) respectively. An additional bed increased admissions for NIV and IMV by 38.6 and 13.6 %, respectively.
Conclusions
Physician decisions for elderly patients had low agreement and varied greatly with bed availability and knowledge of patient preferences.
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Acknowledgments
We thank A. Wolfe, MD, for her assistance in preparing the manuscript and Alexis Tabah for building and managing the study website. We thank all ICU physicians of the ETHICA group who participated in the study. This study was supported by the French Society for Critical Care (SRLF) and the Fondation de France. These organisations had no role in the design or conducting of the study; in data collection, management, or interpretation; or in the writing of the manuscript.
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Part I of the ETHICA study can be found at: doi:10.1007/s00134-013-2976-y; an editorial discussing both parts of the ETHICA study can be found at: doi:10.1007/s00134-013-2968-y.
On behalf of the ETHICA group; the members of the ETHICA group who acted as co-investigators are listed in the Appendix.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Appendix
Appendix
ETHICA Group List of physicians who participated in the study (all in France).
Allou Nicolas, Surgical ICU, University Bichat Hospital, Paris.
Allyn Jérome, Surgical ICU, University Bichat Hospital, Paris.
Ara-Somohano Claire, University Albert Michallon Hospital, Grenoble.
Asehnoune Karim, Surgical ICU, University Hotel Dieu, Nantes.
Baillat Laetitia, Medical-Surgical ICU, Arbeltier General Hospital, Coulommiers.
Berkelmans Frantz, Medical-Surgical ICU, General Hospital, Dunkerque.
Beuret Pascal, Medical-Surgical ICU, General Hospital, Roanne.
Blanié Antonia, Anesthesiology and ICU Department, University Bicêtre Hospital, Le Kremlin Bicêtre.
Bonadona, Agnés, University Albert Michallon Hospital, Grenoble.
Bonnaire Rémi, Medical-Surgical ICU, Robert Ballanger Hospital, Aulnay Sous-Bois.
Bonneton Benjamin, Medical-Surgical ICU, Arbeltier General Hospital, Couloummiers.
Bornstain Caroline, Medical-Surgical Hospital, Le Raincy Hospital, Montfermeil.
Bougerol François, Medical-Surgical ICU, General Hospital, Dieppe.
Boukantar, Madjid, Medical-Surgical ICU, Saint Joseph Hospital Network, Paris.
Bretsztajn Alain, Medical-Surgical ICU, General Hospital, Salon de Provence.
Brunel Elodie, Medical-Surgical ICU, University Purpan Hospital, Toulouse.
Carr Julie, Anesthesiology and ICU B Department, University Saint-Eloi Hospital, Montpellier.
Chalumeau-Lemoine Ludivine, Medical-Surgical ICU, Institut Gustave Roussy Hospital, Villejuif.
Chanques Gérald, Anesthesiology and ICU B Department, University Saint-Eloi Hospital, Montpellier.
Charpentier Julien, Medical ICU, University Cochin Hospital, Paris.
Charron Cyril, Medical-Surgical ICU, University Ambroise Paré Hospital, Boulogne Billancourt.
Ciroldi Magali, Medical-Surgical ICU, General Hospital André Grégoire, Montreuil.
Clec’h Christophe, Medical-Surgical ICU, University Avicenne Hospital, Bobigny.
Combettes Evelyne, Neurology Medical-Surgical ICU, University La Pitié Salpêtrière Hospital, Paris.
Conia Alexandre, Medical-Surgical ICU, General Victor Jousselin Hospital, Dreux.
Conrad Marie, Medical ICU, University Central Hospital, Nancy.
Coquet Isaline, Medical-Surgical ICU, Foch Hospital, Suresnes.
Coudrot Maud, Medical-Surgical ICU G, University North Hospital, Saint Etienne.
Cravoisy-Popovic Aurélie, Medical ICU, University Central Hospital, Nancy.
Darmon Michael, Medical-Surgical ICU G, University North Hospital, Saint-Priest-en-Jarez.
De Jonghe Bernard, Medical-Surgical ICU, General Hospital, Poissy.
Debarre Matthieu, Neuro-Surgical ICU, University La Pitié Salpêtrière Hospital, Paris.
Demoule Alexandre, Respiratory and Medical ICU, University La Pitié Salpêtrière Hospital, Paris.
Demory Didier, Medical-Surgical ICU, General Font Pré Hospital, Toulon.
Donati Stéphane-Yannis, Medical-Surgical ICU, General Font Pré Hospital, Toulon.
Durand-Gasselin Jacques, Medical-Surgical ICU, General Font Pré Hospital, Toulon.
Ede Cyrille, Medical-Surgical ICU, General Hospital, Auxerre.
Fassier Thomas, Medical Information, Evaluation and Research, University Hospices Civils, Lyon.
Fieux Fabienne, Surgical ICU, University Saint Louis Hospital, Paris.
Floccard Bernard, Medical-Surgical ICU, University Edouard Herriot Hospital, Lyon.
Galbois Arnaud, Medical ICU, University Saint Antoine Hospital, Paris.
Gamelin Alexandre, Burn ICU, University Roger Salengro Hospital, Lille.
Gauss Tobias, Anesthesiology Department, University Beaujon Hospital, Clichy.
Girault Christophe, Medical ICU, University Charles Nicolle Hospital, Rouen.
Grimaldi David, Medical ICU, University Cochin Hospital, Paris.
Guidet Bertrand, Medical ICU, University Saint Antoine Hospital, Paris.
Hamdi Aïcha, Medical-Surgical ICU, General André Grégoire Hospital, Montreuil.
Hamidfar-Roy Rébecca, Medical ICU, University Albert Michallon Hospital, Grenoble.
Hamzaoui Olfa, Medical ICU, University Antoine Béclère, Hospital, Clamart.
Hérault Marie Christine, Medical-Surgical ICU, University Albert Michallon Hospital, Grenoble.
Holzapfel Laurent, Medical-Surgical ICU, General Hospital Fleyriat, Bourg en Bresse.
Hurel Dominique, Medical-Surgical ICU, General François Quesnay Hospital, Mantes la Jolie.
Jaber Samir, Anesthesiology and ICU B Department, University Saint-Eloi Hospital, Montpellier.
Kaidomar Michel, Medical-Surgical ICU, General Hospital, Fréjus.
Kallel Hatem, Medical-Surgical ICU, General Andrée Rosemon Hospital, Cayenne.
Lancrin Frédéric, Anesthesiology and ICU Department, Institut Gustave Roussy Hospital, Villejuif.
Laplace Christian, Surgical ICU, Bicêtre University Hospital, Le Kremlin Bicêtre.
Lau Nicolas, Medical-Surgical ICU, Saint Joseph Hospital Network, Paris.
Lebert Christine, Medical-Surgical ICU, Les Oudaries Hospital, La Roche-Sur-Yon.
Lefebvre Aurélie, Medical ICU, University Hôtel Dieu Hospital, Paris.
Legriel Stéphane, Medical-Surgical ICU, Mignot Hospital, Le Chesnay.
Lemiale Virginie, Medical ICU, University Saint Louis Hospital, Paris.
Lenclud Christophe, Medical ICU, University Lariboisière Hospital, Paris.
Lerolle Nicolas, Medical ICU, University Hospital, Angers.
Machado Sonia, Metabolic ICU, University Lapeyronie Hospital, Montpellier.
Max Adeline, Medical-Surgical ICU, Saint Joseph Hospital Network, Paris.
Maxime Virginie, Medical ICU, University Raymond Poincaré Hospital, Garches.
Mayaux Julien, Respiratory and Medical ICU, University La Pitié Salpêtrière Hospital, Paris.
Merceron Sybille, Medical-Surgical ICU, Mignot Hospital, Le Chesnay.
Minet Clémence, Medical ICU, University Albert Michallon Hospital, Grenoble.
Mongardon Nicolas, Medical ICU, University Cochin Hospital, Paris.
Offenstadt Georges, Medical ICU, University Saint Antoine Hospital, Paris.
Parrot Antoine, Respiratory ICU, University Tenon, Hospital, Paris.
Pease Sebastian, Surgical ICU, University Beaujon Hospital, Clichy.
Pene Fréderic, Medical ICU, University Cochin Hospital, Paris.
Percheron Stéphanie, Medical-Surgical ICU, General Sud Essonne Dourdan-Etampes Hospital, Etampes.
Philippon-Jouve Bénédicte, Medical-Surgical ICU, General Hospital, Roanne.
Pradère Pauline, Medical ICU, University Tenon, Hospital, Paris.
Rabbat Antoine, Medical ICU, University Hôtel Dieu Hospital, Paris.
Raux Mathieu, Surgical ICU, University La Pitié Salpêtrière Hospital, Paris.
Renault Anne, Medical ICU, University La Cavale Blanche Hospital, Brest.
Richard Jean-Christophe, Medical ICU, University La Croix Rousse Hospital, Lyon.
Ricome Sylvie, Medical ICU, University Cochin Hospital, Paris.
Rigaud Jean-Philippe, Medical-Surgical ICU, General Hospital, Dieppe.
Riu Beatrice, Medical-Surgical ICU, University Purpan Hospital, Toulouse.
Rodriguez Luc, Medical ICU, General Pays D’Aix Hospital, Aix en Provence.
Roquilly Antoine, Medical ICU, University Hospital, Nantes.
Roussel Christophe, Medical-Surgical ICU, General Hospital, Fréjus.
Saissi Gilbert, Surgical ICU, University Caremeau Hospital, Nimes.
Schnell David, Medical ICU, University Saint Louis Hospital, Paris.
Schwebel Carole, Medical ICU, University Albert Michallon Hospital, Grenoble.
Seguin Thierry, Medical-Surgical ICU, University Rangueil Hospital, Toulouse.
Serveaux Marianne, Metabolic ICU, University Lapeyronie Hospital, Montpellier.
Siami Shidasp, General Sud Essonne Dourdan-Etampes Hospital, Etampes.
Tamion Fabienne, Medical ICU, University Charles Nicolle Hospital, Rouen.
Theodore Jonathan, Medical-Surgical ICU, General Hospital, Salon de Provence.
Touati Samia, Medical-Surgical ICU, General Hospital, Meaux.
Willems Vincent, Medical-Surgical ICU General Joseph Imbert Hospital, Arles.
Zuber Benjamin, Medical ICU, University Cochin Hospital, Paris.
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Garrouste-Orgeas, M., Tabah, A., Vesin, A. et al. The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over. Intensive Care Med 39, 1574–1583 (2013). https://doi.org/10.1007/s00134-013-2977-x
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DOI: https://doi.org/10.1007/s00134-013-2977-x