National questionnaire survey on what influences doctors' decisions about admission to intensive care
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《英国医生杂志》
1 Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, CH-1211 Geneva 14, Switzerland, 2 Quality of Care Unit, Geneva University Hospitals, 3 Medical Intensive Care Division, Geneva University Hospitals
Correspondence to: M Escher monica.escher@hcuge.ch
Abstract
In the United States and Canada intensive care accounts for 20% and 8% of inpatient hospital costs, respectively.1 Fair allocation of this scarce and expensive resource is the doctors' responsibility. Although guidelines have been developed to help doctors decide on who to admit to intensive care,2-4 they may be difficult to put into practice.5 In particular, the process by which doctors identify patients with a "reasonable prospect of substantial recovery" warranting intensive care is not well known.
Characteristics of patients that influence admission to intensive care are age, severity of illness, and reason for admission.5 6 Availability of beds has been inconsistently associated with triage decisions.6 7 Cognitive factors may also influence decisions, including biases in doctors' processing of information,8 9 the amount of information available,10 and the underlying disease.11 More specifically, and regardless of prognosis, patients with cancer may have more do not resuscitate orders and receive less cardiopulmonary resuscitation, mechanical ventilation, and intensive care.12-16 The relative importance of these factors for decisions on admission to intensive care is not well known. We assessed what influences doctors' decisions to admit patients to intensive care. In particular we sought to determine if there was a bias against patients with cancer.
Methods
Overall, 21 of 402 eligible doctors declined to participate because they no longer worked in intensive care. Of the remaining 381 doctors, 232 (61%) returned completed questionnaires. Response rates were similar across the eight versions of the questionnaire.
The mean age of respondents was 45.2 years (table 1). Most were men, worked at public hospitals, and were routinely involved in decisions on admissions to intensive care. Many had more than one certification in a medical specialty (n = 137; 59%), the most common being intensive care medicine and anaesthesiology. Most worked in surgical (n = 199; 86%) or medical intensive care (n = 159; 69%), and 15 (7%) worked in paediatric or neonatal intensive care. The mean number of beds in each intensive care unit was 11.4 (SD 6.4). Overall, 105 respondents (45%) reported that a relative or close acquaintance had ever been admitted to intensive care.
Table 1 Characteristics of 232 Swiss doctors who agreed to participate in questionnaire survey on determinants of admission of patients to intensive care. Values are numbers (percentages) unless stated otherwise
Determinants of admission to intensive care
Among the factors influencing decisions on admission to intensive care, most doctors rated as important or very important the prognosis of the acute illness and of the underlying disease and the patients' wishes (figure). Half considered the number of available beds as important. Least influential were patients' religious beliefs, drug and alcohol misuse, psychiatric history, emotional state, and socioeconomic circumstances.
Doctors' ranking of factors when assessing patients for admission to intensive care
Analysis of scenarios
One scenario (myocardial infarction) was designed so as to elicit an acceptance rate close to 100%; 217 respondents (94%) chose to admit the patient. In another scenario (respiratory failure in the presence of relapse with acute leukaemia) refusal was expected from most doctors; however 190 (82%) admitted the patient. Many (n = 105) added a comment, most often (n = 53; 50%) pointing out that they had hardly any choice as the patient was already mechanically ventilated.
Overall, 213 (92%) doctors answered the six remaining vignettes. The mean number of patients admitted to intensive care was 3.3 (SD 1.3) out of six. Three doctors (1%) admitted no one, 12 (6%) admitted one patient, 41 (19%) admitted two patients, 65 (31%) admitted three patients, 55 (26%) admitted four patients, 28 (13%) admitted five patients, and 9 (4%) admitted all six patients. Correlations between decisions on admission were weak (Spearman r - 0.15 to 0.21), indicating that there was no tendency for doctors to admit either all or none of the patients. The overall proportion of admissions across all variations of a given scenario ranged from 46% (fever, dysuria, and renal failure) to 66% (upper gastrointestinal bleeding).
In all the vignettes, admission rates varied significantly according to at least one experimentally manipulated factor (table 2). Having cancer as opposed to a non-cancerous disease did not influence the probability of admission in five scenarios. A patient with breast cancer presenting with haemolytic uraemic syndrome was, however, three times less likely to be admitted to intensive care than a patient with AIDS with the same condition. Respondents admitted a mean of 1.6 patients with cancer and 1.7 patients with non-cancerous disease (P = 0.68).
Table 2 Influence of factors assessed in hypothetical scenarios on probability of being admitted to intensive care
The patient's wish to receive maximal treatment was associated with an increased odds of admission, as were certain personality traits. Patients described as upbeat and sociable or strong and courageous were more likely to be admitted than patients described as sad and withdrawn or anxious and discouraged. The patient's means of living did not affect the probability of admission, but social involvement did. Younger age was associated with a slightly higher admission rate in the two scenarios where this factor was assessed. Availability of three intensive care beds was related to a higher probability of a patient being admitted. A difference was found in the way the family's attitude was considered. An explicit request increased the chances of admission whereas a non-verbal emotional attachment did not.
Matched analyses confirmed that patients' wishes, personality traits, age, and availability of intensive care beds were significantly associated with the probability of admission (table 3).
Table 3 Analysis of matched pairs of scenarios
Discussion
Jacobs P, Noseworthy TW. National estimates of intensive care utilization and costs: Canada and the United States. Crit Care Med 1990;18: 1282-6.
Society of Critical Medicine Ethics Committee. Consensus statement on the triage of critically ill patients. JAMA 1994;271: 1200-3.
American Thoracic Society. Fair allocation of intensive care unit resources. Am J Respir Crit Care Med 1997;156: 1282-1301.
Society of Critical Medicine. Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med 1999;27: 633-8.
Azoulay E, Pochard F, Chevret S, Vinsonneau C, Garrouste M, Cohen Y, et al. Compliance with triage to intensive care recommendations. Crit Care Med 2001;29: 2132-6.
Sprung CL, Eidelman LA. Triage decisions for intensive care in terminally ill patients. Intensive Care Med 1997;23: 1011-4.
Joynt G, Gomersall C, Tan P, Lee A, Cheng C, Wang N. Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome. Intensive Care Med 2001;27: 1459-65.
Eisenberg J. Sociologic influences on decision-making by clinicians. Ann Intern Med 1979;90: 957-64.
Redelmeier D, Ferris L, Tu J, Hux J, Schull M. Problems for clinical judgement: introducing cognitive psychology as one more basic science. Can Med Assoc J 2001;164: 358-60.
Nuckton T, List N. Age as a factor in critical care unit admission. Arch Intern Med 1995;155: 1087-92.
Ghusn HF, Teasdale TA, Boyer K. Characteristics of patients receiving or foregoing resuscitation at the time of cardiopulmonary arrest. J Am Geriatr Soc 1997;45: 1118-22.
Lawrence V, Clark G. Cancer and resuscitation. Does the diagnosis affect the decision? Arch Intern Med 1987;147: 1637-40.
Hanson L, Danis M, Garrett J, Mutran E. Who decides? Physicians' willingness to use life-sustaining treatment. Arch Intern Med 1996;156: 785-9.
Wachter R, Luce J, Hearst N, Lo B. Decisions about resuscitation: inequities among patients with different diseases but similar prognoses. Ann Intern Med 1989;111: 525-32.
Tanvetyanon T, Leighton J. Life-sustaining treatments in patients who died of chronic congestive heart failure compared with metastatic cancer. Crit Care Med 2003;31: 60-4.
Claessens MT, Lynn J, Zhong Z, Desbiens NA, Phillips RS, Wu AW, et al. Dying with lung cancer or chronic obstructive pulmonary disease: insights from SUPPORT study (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). J Am Geriatr Soc 2000;48: S146-53.
Vincent JL. Information in the ICU: are we being honest with our patient? The results of a European questionnaire. Intensive Care Med 1998;24: 1251-6.
Furnham A, Simmons K, McClelland A. Decisions concerning the allocation of scarce medical resources. J Soc Behav Pers 2000;15: 185-200.
Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive care unit. Lancet 2000;356: 185-9.
Suhl J, Simons P, Reedy T, Garrick T. Myth of substituted judgment. Surrogate decision making regarding life support is unreliable. Arch Intern Med 1994;154: 90-6.
Coppola KM, Ditto PH, Danks JH, Smucker WD. Accuracy of primary care and hospital-based physicians' predictions of elderly outpatients' treatment preferences with and without advance directives. Arch Intern Med 2001;161: 431-40.
Ely JW, Peters PG Jr, Zweig S, Elder N, Schneider FD. The physician's decision to use tube feedings: the role of the family, the living will, and the Cruzan decision. J Am Geriatr Soc 1992;40: 471-5.
Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 2000;28: 3044-9.(Monica Escher, senior reg)
Correspondence to: M Escher monica.escher@hcuge.ch
Abstract
In the United States and Canada intensive care accounts for 20% and 8% of inpatient hospital costs, respectively.1 Fair allocation of this scarce and expensive resource is the doctors' responsibility. Although guidelines have been developed to help doctors decide on who to admit to intensive care,2-4 they may be difficult to put into practice.5 In particular, the process by which doctors identify patients with a "reasonable prospect of substantial recovery" warranting intensive care is not well known.
Characteristics of patients that influence admission to intensive care are age, severity of illness, and reason for admission.5 6 Availability of beds has been inconsistently associated with triage decisions.6 7 Cognitive factors may also influence decisions, including biases in doctors' processing of information,8 9 the amount of information available,10 and the underlying disease.11 More specifically, and regardless of prognosis, patients with cancer may have more do not resuscitate orders and receive less cardiopulmonary resuscitation, mechanical ventilation, and intensive care.12-16 The relative importance of these factors for decisions on admission to intensive care is not well known. We assessed what influences doctors' decisions to admit patients to intensive care. In particular we sought to determine if there was a bias against patients with cancer.
Methods
Overall, 21 of 402 eligible doctors declined to participate because they no longer worked in intensive care. Of the remaining 381 doctors, 232 (61%) returned completed questionnaires. Response rates were similar across the eight versions of the questionnaire.
The mean age of respondents was 45.2 years (table 1). Most were men, worked at public hospitals, and were routinely involved in decisions on admissions to intensive care. Many had more than one certification in a medical specialty (n = 137; 59%), the most common being intensive care medicine and anaesthesiology. Most worked in surgical (n = 199; 86%) or medical intensive care (n = 159; 69%), and 15 (7%) worked in paediatric or neonatal intensive care. The mean number of beds in each intensive care unit was 11.4 (SD 6.4). Overall, 105 respondents (45%) reported that a relative or close acquaintance had ever been admitted to intensive care.
Table 1 Characteristics of 232 Swiss doctors who agreed to participate in questionnaire survey on determinants of admission of patients to intensive care. Values are numbers (percentages) unless stated otherwise
Determinants of admission to intensive care
Among the factors influencing decisions on admission to intensive care, most doctors rated as important or very important the prognosis of the acute illness and of the underlying disease and the patients' wishes (figure). Half considered the number of available beds as important. Least influential were patients' religious beliefs, drug and alcohol misuse, psychiatric history, emotional state, and socioeconomic circumstances.
Doctors' ranking of factors when assessing patients for admission to intensive care
Analysis of scenarios
One scenario (myocardial infarction) was designed so as to elicit an acceptance rate close to 100%; 217 respondents (94%) chose to admit the patient. In another scenario (respiratory failure in the presence of relapse with acute leukaemia) refusal was expected from most doctors; however 190 (82%) admitted the patient. Many (n = 105) added a comment, most often (n = 53; 50%) pointing out that they had hardly any choice as the patient was already mechanically ventilated.
Overall, 213 (92%) doctors answered the six remaining vignettes. The mean number of patients admitted to intensive care was 3.3 (SD 1.3) out of six. Three doctors (1%) admitted no one, 12 (6%) admitted one patient, 41 (19%) admitted two patients, 65 (31%) admitted three patients, 55 (26%) admitted four patients, 28 (13%) admitted five patients, and 9 (4%) admitted all six patients. Correlations between decisions on admission were weak (Spearman r - 0.15 to 0.21), indicating that there was no tendency for doctors to admit either all or none of the patients. The overall proportion of admissions across all variations of a given scenario ranged from 46% (fever, dysuria, and renal failure) to 66% (upper gastrointestinal bleeding).
In all the vignettes, admission rates varied significantly according to at least one experimentally manipulated factor (table 2). Having cancer as opposed to a non-cancerous disease did not influence the probability of admission in five scenarios. A patient with breast cancer presenting with haemolytic uraemic syndrome was, however, three times less likely to be admitted to intensive care than a patient with AIDS with the same condition. Respondents admitted a mean of 1.6 patients with cancer and 1.7 patients with non-cancerous disease (P = 0.68).
Table 2 Influence of factors assessed in hypothetical scenarios on probability of being admitted to intensive care
The patient's wish to receive maximal treatment was associated with an increased odds of admission, as were certain personality traits. Patients described as upbeat and sociable or strong and courageous were more likely to be admitted than patients described as sad and withdrawn or anxious and discouraged. The patient's means of living did not affect the probability of admission, but social involvement did. Younger age was associated with a slightly higher admission rate in the two scenarios where this factor was assessed. Availability of three intensive care beds was related to a higher probability of a patient being admitted. A difference was found in the way the family's attitude was considered. An explicit request increased the chances of admission whereas a non-verbal emotional attachment did not.
Matched analyses confirmed that patients' wishes, personality traits, age, and availability of intensive care beds were significantly associated with the probability of admission (table 3).
Table 3 Analysis of matched pairs of scenarios
Discussion
Jacobs P, Noseworthy TW. National estimates of intensive care utilization and costs: Canada and the United States. Crit Care Med 1990;18: 1282-6.
Society of Critical Medicine Ethics Committee. Consensus statement on the triage of critically ill patients. JAMA 1994;271: 1200-3.
American Thoracic Society. Fair allocation of intensive care unit resources. Am J Respir Crit Care Med 1997;156: 1282-1301.
Society of Critical Medicine. Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med 1999;27: 633-8.
Azoulay E, Pochard F, Chevret S, Vinsonneau C, Garrouste M, Cohen Y, et al. Compliance with triage to intensive care recommendations. Crit Care Med 2001;29: 2132-6.
Sprung CL, Eidelman LA. Triage decisions for intensive care in terminally ill patients. Intensive Care Med 1997;23: 1011-4.
Joynt G, Gomersall C, Tan P, Lee A, Cheng C, Wang N. Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome. Intensive Care Med 2001;27: 1459-65.
Eisenberg J. Sociologic influences on decision-making by clinicians. Ann Intern Med 1979;90: 957-64.
Redelmeier D, Ferris L, Tu J, Hux J, Schull M. Problems for clinical judgement: introducing cognitive psychology as one more basic science. Can Med Assoc J 2001;164: 358-60.
Nuckton T, List N. Age as a factor in critical care unit admission. Arch Intern Med 1995;155: 1087-92.
Ghusn HF, Teasdale TA, Boyer K. Characteristics of patients receiving or foregoing resuscitation at the time of cardiopulmonary arrest. J Am Geriatr Soc 1997;45: 1118-22.
Lawrence V, Clark G. Cancer and resuscitation. Does the diagnosis affect the decision? Arch Intern Med 1987;147: 1637-40.
Hanson L, Danis M, Garrett J, Mutran E. Who decides? Physicians' willingness to use life-sustaining treatment. Arch Intern Med 1996;156: 785-9.
Wachter R, Luce J, Hearst N, Lo B. Decisions about resuscitation: inequities among patients with different diseases but similar prognoses. Ann Intern Med 1989;111: 525-32.
Tanvetyanon T, Leighton J. Life-sustaining treatments in patients who died of chronic congestive heart failure compared with metastatic cancer. Crit Care Med 2003;31: 60-4.
Claessens MT, Lynn J, Zhong Z, Desbiens NA, Phillips RS, Wu AW, et al. Dying with lung cancer or chronic obstructive pulmonary disease: insights from SUPPORT study (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). J Am Geriatr Soc 2000;48: S146-53.
Vincent JL. Information in the ICU: are we being honest with our patient? The results of a European questionnaire. Intensive Care Med 1998;24: 1251-6.
Furnham A, Simmons K, McClelland A. Decisions concerning the allocation of scarce medical resources. J Soc Behav Pers 2000;15: 185-200.
Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive care unit. Lancet 2000;356: 185-9.
Suhl J, Simons P, Reedy T, Garrick T. Myth of substituted judgment. Surrogate decision making regarding life support is unreliable. Arch Intern Med 1994;154: 90-6.
Coppola KM, Ditto PH, Danks JH, Smucker WD. Accuracy of primary care and hospital-based physicians' predictions of elderly outpatients' treatment preferences with and without advance directives. Arch Intern Med 2001;161: 431-40.
Ely JW, Peters PG Jr, Zweig S, Elder N, Schneider FD. The physician's decision to use tube feedings: the role of the family, the living will, and the Cruzan decision. J Am Geriatr Soc 1992;40: 471-5.
Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 2000;28: 3044-9.(Monica Escher, senior reg)