Department of Intensive Care, François Mitterrand, University Hospital, Dijon, France.
Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France.
PLoS One. 2019 Sep 6;14(9):e0222039. doi: 10.1371/journal.pone.0222039. eCollection 2019.
We sought to describe the characteristics that lead physicians to perceive a stay in the intensive care unit (ICU) as being non-beneficial for the patient.
In the first step, we used a multidisciplinary focus group to define the characteristics that lead physicians to consider a stay in the ICU as non-beneficial for the patient. In the second step, we assessed the proportion of admissions that would be perceived by the ICU physicians as non-beneficial for the patient according to our focus group's definition, in a large population of ICU admissions in 4 French ICUs over a period of 4 months.
Among 1075 patients admitted to participating ICUs during the study period, 155 stays were considered non-beneficial for the patient, yielding a frequency of 14.4% [95% confidence interval (CI) 8.9, 19.9]. Average age of these patients was 72 ±12.8 years. Mortality was 43.2% in-ICU [95%CI 35.4, 51.0], 55% [95%CI 47.2, 62.8] in-hospital. The criteria retained by the focus group to define a non-beneficial ICU stay were: patient refusal of ICU care (23.2% [95%CI 16.5, 29.8]), and referring physician's desire not to have the patient admitted (11.6% [95%CI 6.6, 16.6]). The characteristics that led physicians to perceive the stay as non-beneficial were: patient's age (36.8% [95%CI 29.2, 44.4]), unlikelihood of recovering autonomy (61.9% [95%CI 54.3, 69.6]), prior poor quality of life (60% [95%CI 52.3, 67.7]), terminal status of chronic disease (56.1% [95%CI 48.3, 63.9]), and all therapeutic options have been exhausted (35.5% [95%CI 27.9, 43.0]). Factors that explained admission to the ICU of patients whose stay was subsequently judged to be non-beneficial included: lack of knowledge of patient's wishes (52% [95%CI 44.1, 59.9]); decisional incapacity (sedation) (69.7% [95%CI 62.5, 76.9]); inability to contact family (34% [95%CI 26.5, 41.5]); pressure to admit (from family or other physicians) (50.3% [95%CI 42.4, 58.2]).
Non-beneficial ICU stays are frequent. ICU admissions need to be anticipated, so that patients who would yield greater benefit from other care pathways can be correctly oriented in a timely manner.
我们旨在描述导致医生认为 ICU 住院对患者无益的特征。
在第一步中，我们使用多学科焦点小组来定义导致医生认为 ICU 住院对患者无益的特征。在第二步中，我们根据焦点小组的定义，评估了在法国 4 家 ICU 的 4 个月期间，大量 ICU 入院患者中，有多少患者被 ICU 医生认为对患者无益。
在研究期间入住参与 ICU 的 1075 名患者中，有 155 名患者的住院被认为对患者无益，发生率为 14.4%[95%置信区间 (CI) 8.9, 19.9]。这些患者的平均年龄为 72 ±12.8 岁。院内 ICU 死亡率为 43.2%[95%CI 35.4, 51.0]，住院死亡率为 55%[95%CI 47.2, 62.8]。焦点小组定义为 ICU 无益住院的标准为：患者拒绝 ICU 治疗（23.2%[95%CI 16.5, 29.8]）和主治医生不希望患者入院（11.6%[95%CI 6.6, 16.6]）。导致医生认为住院无益的特征为：患者年龄（36.8%[95%CI 29.2, 44.4]）、不太可能恢复自主能力（61.9%[95%CI 54.3, 69.6]）、先前生活质量差（60%[95%CI 52.3, 67.7]）、慢性疾病终末期状态（56.1%[95%CI 48.3, 63.9]）和所有治疗方案均已用尽（35.5%[95%CI 27.9, 43.0]）。解释随后被判断为无益的 ICU 住院患者入院的因素包括：缺乏对患者意愿的了解（52%[95%CI 44.1, 59.9]）；决策能力丧失（镇静）（69.7%[95%CI 62.5, 76.9]）；无法联系家属（34%[95%CI 26.5, 41.5]）；入院压力（来自家属或其他医生）（50.3%[95%CI 42.4, 58.2]）。
无益的 ICU 住院很常见。需要对 ICU 入院进行预测，以便及时为那些从其他治疗途径中获益更大的患者提供正确的指导。
