Project

Back to overview

Medical and non-medical factors that influence the decision to admit a seriously ill patient to intensive care

English title Medical and non-medical factors that influence the decision to admit a seriously ill patient to intensive care
Applicant Escher Monica
Number 139304
Funding scheme NRP 67 End of Life
Research institution Hôpitaux Universitaires de Genève
Institution of higher education University of Geneva - GE
Main discipline Internal Medicine
Start/End 01.11.2012 - 31.07.2017
Approved amount 233'271.00
Show all

Keywords (6)

physician decision-making; intensive care; terminal care ; triage; ethics; resource allocation

Lay Summary (German)

Lead
Oft werden Menschen am Lebensende in Intensivpflegestationen (IPS) eingewiesen. Dieses Projekt untersucht, auf welcher Grundlage Ärzte und Ärztinnen die Entscheidung treffen, einen schwer kranken, stationär betreuten Patienten auf die Intensivstation zu verlegen oder nicht.
Lay summary

Hintergrund
Bei der Intensivmedizin handelt es sich um eine besondere und kostenintensive Gesundheitsleistung. Ein Patient ist bei einem Aufenthalt auf der Intensivstation einer grossen körperlichen und emotionalen Belastung ausgesetzt. Daher sollten die Chancen des Überlebens und die Lebensqualität signifikant erhöht werden. Gleichzeitig muss die Verlegung mit Einwilligung der Patienten vorgenommen werden. Die Betroffenen sind vor allem gebrechliche Patienten fortgeschrittenen Alters und Menschen, die an einer schweren Erkrankung leiden und denen eine schlechte Prognose gestellt wurde. Der Prozess der Entscheidungsfindung muss gerecht sein. Bei der Abwägung der Umstände sollten alle Patienten gleich behandelt werden.

Ziel
Die Studie will erforschen, welche Faktoren den Entscheidungen der Ärzte und Ärztinnen für oder gegen die Verlegung eines Patienten auf die Intensivpflegestation zugrunde liegen. Gespräche mit Internisten und Intensivmedizinern stellen ein Teil der Studie dar. Darüber hinaus erfolgt eine Evaluation von Entscheidungskriterien mittels Fragebogen. Einerseits soll also ermittelt werden, ob IPS-Ärzte und -Ärztinnen das Sterberisiko bei Patienten, die für eine Verlegung auf die IPS vorgesehen sind, in gleicher Weise einschätzen wie Stationsärzte und -ärztinnen. Andererseits soll eruiert werden, aufgrund welcher Faktoren diese Einschätzungen zustande gekommen sind.

Bedeutung
Anhand der Ergebnisse sollen bei der Einweisung von Patienten in die Intensivpflegestation Verbesserungsmöglichkeiten eruiert und Strategien zur Förderung einer gerechten Verteilung dieser Gesundheitsressourcen entwickelt werden.

Direct link to Lay Summary Last update: 18.06.2013

Lay Summary (French)

Lead
Ce projet étudie sur quelle base les médecins prennent la décision de transférer ou non un patient hospitalisé souffrant d’une maladie grave de mauvais pronostic à l’unité de soins intensifs.
Lay summary

Contexte
Les soins intensifs sont des prestations de santé particulières et coûteuses. Un patient séjournant en unité de soins intensifs est soumis à une lourde charge physique et émotionnelle, qui ne se justifie que si ses chances de survie et sa qualité de vie s’améliorent de manière significative. De plus, le transfert doit être en accord avec les souhaits du patient. Il peut être particulièrement difficile d’évaluer le bénéfice réel des soins intensifs pour des patients très fragiles, d’âge avancé et des personnes souffrant d’une maladie grave et ayant un mauvais pronostic. Le processus décisionnel doit être équitable. S’agissant par exemple de soupeser les circonstances, il convient de traiter tous les patients à égalité.

But
L’étude s’interroge sur les facteurs qui conduisent les médecins à transférer ou non un patient à l’unité de soins intensifs. Des entretiens avec des spécialistes de médecine interne et de médecine intensive forment une partie de l’étude. De plus, une évaluation des critères de décision est réalisée à l’aide d’un questionnaire. Il s’agit de déterminer d’une part si les médecins d’USI évaluent de la même manière que leurs collègues de médecine interne le risque de décès des patients. D’autre part, nous voulons examiner en fonction de quels facteurs ces évaluations sont effectuées.

Portée
Les résultats devraient permettre de déterminer des possibilités d’amélioration lors de l’évaluation de patients pour lesquels un transfert en unité de soins intensifs est envisagé et d’élaborer des stratégies favorables à une répartition équitable de cette ressource de santé.

Direct link to Lay Summary Last update: 18.06.2013

Lay Summary (English)

Lead
Persons at the end of life are often admitted to intensive care units (ICUs). This study examines how physicians make the decision to admit or not admit a seriously ill hospitalized patient to the ICU.
Lay summary

Background
Intensive care is a special and costly medical service. A patient in the ICU is under a great deal of physical and emotional burden. The aim is to significantly increase survival rates and quality of life. At the same time, transfers to the ICU must be done with the patients' agreement. The patients are mainly frail and elderly persons and persons with serious illnesses and therefore poor prognoses. The decision-making process has to be fair. When the circumstances are assessed, all patients should be treated equitably.

Aim
This study aims to find out what factors form the basis for physicians' decisions to transfer or not transfer a hospital patient to the ICU. Interviews with internists and intensive care physicians form one part of the study. In addition, decision criteria will be evaluated by questionnaire. The study aims to find out, for one, whether ICU physicians’ assessments of the likelihood of death of patients planned to be transferred to the ICU are the same as ward physicians' assessments. For another, the aim is to uncover what factors these assessments are based on.

Significance
The results of the study should contribute towards discovering possible improvements in admission of patients to the ICU and towards developing strategies for equitable distribution of these health care resources.

Direct link to Lay Summary Last update: 18.06.2013

Responsible applicant and co-applicants

Employees

Publications

Publication
Internists' and intensivists' roles in intensive care admission decisions: a qualitative study.
CullatiStéphane, HudelsonPatricia, RicouBara, Nendaz Mathieu, PernegerThomas, EscherMonica (2018), Internists' and intensivists' roles in intensive care admission decisions: a qualitative study., in BMC Health Services Research, 18(1), 620.

Collaboration

Group / person Country
Types of collaboration
Geneva University Hospitals Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results

Scientific events

Active participation

Title Type of contribution Title of article or contribution Date Place Persons involved
Congrès national des soins palliatifs Talk given at a conference Short-term versus long-term prognosis in decisions to admit patients with advanced diseases to intensive care. 14.09.2018 Bienne, Switzerland Escher Monica; Perneger Thomas;
3ème Assemblée Annuelle de la Société Suisse de Médecine Interne Générale Poster Short-term versus long-term prognosis in decisions to admit patients with advanced diseases to intensive care. 30.05.2018 Basel, Switzerland Perneger Thomas; Escher Monica;
10th World Research Congress of the European Association for Palliative Care Poster Contextual factors influencing the admission of patients with advanced diseases to intensive care. 24.05.2018 Bern, Switzerland Escher Monica; Perneger Thomas;
15th World Congress of the European Association for Palliative Care Talk given at a conference Medical collaboration during ICU admission decisions for seriously ill patients: a qualitative study of internists' and ICU physicians' perceptions 18.05.2017 Madrid, Spain Escher Monica;
15th World Congress of the European Association for Palliative Care Poster Life and death: a comparison of ICU physicians’ and internists’ survival predictions for patients assessed for intensive care. 18.05.2017 Madrid, Spain Escher Monica; Perneger Thomas;
2ème Assemblée Annuelle de la Société Suisse de Médecine Interne Générale Poster Life and death: a comparison of ICU physicians’ and internists’ survival predictions for patients assessed for intensive care. 03.05.2017 Lausanne, Switzerland Nendaz Mathieu; Perneger Thomas; Escher Monica;
2ème Assemblée Annuelle de la Société Suisse de Médecine Interne Générale Poster Medical collaboration during ICU admission decisions: a qualitative study of internists' and ICU physicians' perceptions 03.05.2017 Lausanne, Switzerland Escher Monica; Nendaz Mathieu;
9th World Research Congress of the European Association for Palliative Care Poster Admission to intensive care at the end of life: internal medicine and intensive care doctors' expected roles during triage. A qualitative study 09.06.2016 Dublin, Ireland Escher Monica;
1ère Assemblée Annuelle de la Société Suisse de Médecine Interne Générale Poster Intensive care at the end of life: internal medicine and intensive care physicians’ perceived roles during triage. 25.05.2016 Basel, Switzerland Nendaz Mathieu; Escher Monica;
Journées nationales des soins palliatifs 2015 Poster The role of code status in the triage of hospitalized seriously ill patients to intensive care: a qualitative study of internists’ and ICU doctors’ experiences. 02.12.2015 Bern, Switzerland Escher Monica;
Meeting of the group for qualitative research, Geneva University Hospitals Individual talk Medical and non-medical factors that influence the decision to admit a seriously ill patient to intensive care 23.11.2015 Geneva, Switzerland Escher Monica; Cullati Stéphane;
83ème Assemblée Annuelle de la Société Suisse de Médecine Interne Talk given at a conference The role of code status in the triage of hospitalized seriously ill patients to intensive care: a qualitative study of internists’ and ICU doctors’ experiences. 20.05.2015 Basel, Switzerland Escher Monica; Nendaz Mathieu;
14th World Congress of the European Association for Palliative Care Talk given at a conference The role of code status in the triage of hospitalized seriously ill patients to intensive care: a qualitative study of internists’ and ICU doctors’ experiences 08.05.2015 Copenhagen, Denmark Escher Monica;
Séminaire annuel de la Société suisse de bioéthique médicale Talk given at a conference Factors influencing the decision to admit a seriously ill patient to intensive care. A qualitative study of internists’ and ICU doctors’ experiences about decision-making. 06.11.2014 Lugano, Switzerland Escher Monica;
Swiss Congress of Intensive Care Medicine Poster Factors influencing the decision to admit a seriously ill patient to intensive care. A qualitative study of internists’ and ICU doctors’ experiences about decision-making 29.10.2014 Interlaken, Switzerland Escher Monica; Ricou Bara;
8th World Research Congress of the European Association for Palliative Care Talk given at a conference The importance of advance care planning for seriously ill patients. A qualitative study of doctors’ experiences about admission to intensive care 05.06.2014 Lleida, Spain Escher Monica;
European and Swiss Congress of Internal Medicine Poster Seriously ill patients in internal medicine: who should be admitted to intensive care? A qualitative study of internists' and ICU doctors' experiences about decision-making. 14.05.2014 Geneva, Switzerland Nendaz Mathieu; Escher Monica;
Conférence nationale sur la recherche en soins palliatifs Académie suisse des sciences médicales – palliative ch Poster Shall this patient in internal medicine be admitted to intensive care? A qualitative study of doctors’ experiences about the decision-making process. 26.11.2013 Bern, Switzerland Escher Monica;


Abstract

Background: Intensive care is a scarce and expensive resource. Although frail elderly patients and patients with a serious underlying illness can benefit from it, they are at high risk of dying during their stay in the intensive care unit (ICU). Uncertainty as to the patient’s outcomes and limited opportunity to involve him in the admission decision process carries a risk of suboptimal decision-making and inappropriate disparity regarding admission to the ICU.Aims: 1) To identify medical and non-medical factors that influence ICU admission decision-making process. 2) To determine their relative importance in actual situations of clinical uncertainty involving seriously ill hospitalized patients at high risk of death within 12 months. 3) To determine if, and how, non-medical factors influence the referring unit physician’s and the ICU physician’s assessments of probabilities of medical outcomes.Methods: Qualitative and quantitative assessments. Physicians working in the Division of General Internal Medicine or in the Division of Intensive Care of the Geneva University Hospitals and directly involved in ICU admission decisions will be included. Socio-demographic characteristics will be collected. In a first qualitative phase, semi-directive, in-depth interviews will be conducted in order to explore physicians’ ideas about what constitutes a sound decision-making process, to explore their perceptions of how the ICU admission decision-making process actually occurs, and to identify medical and non-medical factors that influence the decision-making process. In the second, quantitative phase we will determine by a questionnaire partially based on the qualitative part of the study if there is a discrepancy between the unit and the ICU physician’s assessments of the benefit and burden of care in the ICU compared to care in the unit, as well as which factors influence their assessments, and how. Within 48 hours of a request for ICU admission the questionnaire will be administered to both physicians involved. It will include questions about probabilities of medical outcomes (e.g. one-month survival), questions about non-medical factors identified in the qualitative phase of the study, a question about the physician’s preferred hypothetical admission decision, and a question reflecting his satisfaction with the actual decision. Patient characteristics will be collected and the decision - admission or not - recorded. The independent variables will be patient and physician characteristics, and contextual factors. The outcome variables will be the actual admission decision, the unit and ICU physician’s preferred hypothetical decision, the unit and ICU physician’s perceptions of benefit from intensive care, and the discrepancy in this perception between the two physicians.
-