• D D Benoit, H I Jensen, J Malmgren, V Metaxa, A K Reyners, M Darmon, K Rusinova, D Talmor, A P Meert, L Cancelliere, L Zubek, P Maia, A Michalsen, S Vanheule, KompanjeE J OEJODepartment of Intensive Care Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands., J Decruyenaere, S Vandenberghe, S Vansteelandt, B Gadeyne, B Van den Bulcke, E Azoulay, R D Piers, and DISPROPRICUS study group of the Ethics Section of the European Society of Intensive Care Medicine.
• Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium. dominique.benoit@ugent.be.
• Intensive Care Med. 2018 Jul 1; 44 (7): 1039-1049.

PurposeWhether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown.MethodsIn this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis.ResultsOf the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0-1.00) and 85.9% (75.4-92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20-2.92) or receiving a written TLD (HR 2.32, CI 1.11-4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former.ConclusionEnhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life.

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