• Bo Van den Bulcke, Victoria Metaxa, Anna K Reyners, Katerina Rusinova, Hanne I Jensen, J Malmgren, Michael Darmon, Daniel Talmor, Anne-Pascale Meert, Laura Cancelliere, László Zubek, Paulo Maia, Andrej Michalsen, Kompanje Erwin J O EJO Department of Intensive Care Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands., Peter Vlerick, Jolien Roels, Stijn Vansteelandt, Johan Decruyenaere, Elie Azoulay, Stijn Vanheule, Ruth Piers, Dominique Benoit, and DISPROPRICUS study group of the Ethics Section of the ESICM.
• Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium. bo.vandenbulcke@uzgent.be.
• Intensive Care Med. 2020 Jan 1; 46 (1): 46-56.

PurposeApart from organizational issues, quality of inter-professional collaboration during ethical decision-making may affect the intention to leave one's job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics.MethodsPerceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self-assessment questionnaire, together with job characteristics and intent to leave as a sub-analysis of the Dispropricus study. The validated ethical decision-making climate questionnaire included seven factors: not avoiding decision-making at end-of-life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self-reflective physician leadership, active decision-making at end-of-life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within ICUs, within the different countries.ResultsOf 3610 nurses and 1137 physicians providing ICU bedside care, 63.1% and 62.9% participated, respectively. Of 2992 participating clinicians, 782 (26.1%) had intent to leave, of which 27% nurses, 24% junior and 22.7% senior physicians. After adjustment for country, ICU and clinicians characteristics, mutual respect OR 0.77 (95% CI 0.66- 0.90), open interdisciplinary reflection (OR 0.73 [95% CI 0.62-0.86]) and not avoiding EOL decisions (OR 0.87 [95% CI 0.77-0.98]) were all associated with a lower intent to leave.ConclusionThis is the first large multicenter study showing an independent association between clinicians' intent to leave and the quality of the ethical climate in the ICU. Interventions to reduce intent to leave may be most effective when they focus on improving mutual respect, interdisciplinary reflection and active decision-making at EOL.

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