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Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician's sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient's best interest and discusses steps that could help minimize the impact of these factors on patient care., Author(s): Alison E. Turnbull [sup.1] [sup.2] [sup.3], Sarina K. Sahetya [sup.1], E. Lee Daugherty Biddison [sup.1], Christiane S. Hartog [sup.4] [sup.5] [sup.6], Gordon D. Rubenfeld [sup.7] [sup.8], Dominique D. Benoit [...]

Author(s): Michael Darmon [sup.1] [sup.2] [sup.3], Dominique D. Benoit [sup.4], Marlies Ostermann [sup.5] Author Affiliations: (1) grid.413328.f, 0000 0001 2300 6614, Medical ICU, Saint-Louis University Hospital, AP-HP, , 1 Avenue [...]

Author(s): Sharon Einav [sup.1], Dominique D. Benoit [sup.2] Author Affiliations: (1) 0000 0004 1937 0538, grid.9619.7, Intensive Care Unit of the Shaare Zedek Medical Centre, Hebrew University Faculty of Medicine, [...]

Author(s): Crystal E. Brown [sup.1] [sup.2], Dominique D. Benoit [sup.3], J. Randall Curtis [sup.1] [sup.2] Author Affiliations: (1) 0000000122986657, grid.34477.33, Cambia Palliative Care Center of Excellence, University of Washington, , [...]

Background: Fast medical progress poses a significant challenge to doctors, who are asked to find the right balance between life-prolonging and palliative care. Literature indicates room for enhancing openness to discuss ethical sensitive issues within and between teams, and improving decision-making for benefit of the patient at end-of-life. Methods: Stepped wedge cluster randomized trial design, run across 10 different departments of the Ghent University Hospital between January 2022 and January 2023. Dutch speaking adult patients and one of their relatives will be included for data collection. All 10 departments were randomly assigned to start a 4-month coaching period. Junior and senior doctors will be coached through observation and debrief by a first coach of the interdisciplinary meetings and individual coaching by the second coach to enhance self-reflection and empowering leadership and managing group dynamics with regard to ethical decision-making. Nurses, junior doctors and senior doctors anonymously report perceptions of excessive treatment via the electronic patient file. Once a patient is identified by two or more different clinicians, an email is sent to the second coach and the doctor in charge of the patient. All nurses, junior and senior doctors will be invited to fill out the ethical decision making climate questionnaire at the start and end of the 12-months study period. Primary endpoints are (1) incidence of written do-not-intubate and resuscitate orders in patients potentially receiving excessive treatment and (2) quality of ethical decision-making climate. Secondary endpoints are patient and family well-being and reports on quality of care and communication; and clinician well-being. Tertiairy endpoints are quantitative and qualitative data of doctor leadership quality. Discussion: This is the first randomized control trial exploring the effects of coaching doctors in self-reflection and empowering leadership, and in the management of team dynamics, with regard to ethical decision-making about patients potentially receiving excessive treatment. [ABSTRACT FROM AUTHOR]

Author(s): Katherine R. Courtright [sup.1] [sup.2], Dominique D. Benoit [sup.3], Scott D. Halpern [sup.1] [sup.2] Author Affiliations: (1) 0000 0004 1936 8972, grid.25879.31, Palliative and Advanced Illness Research (PAIR) Center, [...]

Author(s): Dominique D. Benoit [sup.1], Gordon Doig [sup.2], Jean-Francois Timsit [sup.3] Author Affiliations: (1) grid.410566.0, 0000000406263303, Department of Intensive Care, Ghent University Hospital, , Ghent, Belgium (2) grid.1013.3, 000000041936834X, Northern [...]

Author(s): Dominique D. Benoit [sup.1], Marcio Soares [sup.2], Elie Azoulay [sup.3] Author Affiliations: (1) grid.410566.0, 0000000406263303, Medical Unit, Department of Intensive Care, Ghent University Hospital, , De Pintelaan 185, 12K12IB, [...]

Author(s): Renee D. Stapleton [sup.1] , Dominique D. Benoit [sup.2] Author Affiliations: (1) grid.59062.38, 0000000419367689, Pulmonary and Critical Care Medicine, University of Vermont, , Burlington, VT, USA (2) grid.410566.0, 0000000406263303, [...]

Introduction: A decrease in short-term mortality of critically ill cancer patients with an unplanned intensive care unit (ICU) admission has been described. Few studies describe a change over time of 1-year mortality. Therefore, we examined the 1-year mortality of cancer patients (hematological or solid) with an unplanned ICU admission and we described whether the mortality changed over time. Methods: We used the National Intensive Care Evaluation (NICE) registry and extracted all patients with an unplanned ICU admission in the Netherlands between 2008 and 2017. The primary outcome was 1-year mortality, analyzed with a mixed-effects Cox proportional hazard regression. We compared the 1-year mortality of cancer patients to that of patients without cancer. Furthermore, we examined changes in mortality over the study period. Results: We included 470,305 patients: 10,401 with hematological cancer, 35,920 with solid cancer, and 423,984 without cancer. The 1-year mortality rates were 60.1%, 46.2%, and 28.3% respectively (P< .01). Approximately 30% of the cancer patients surviving their hospital admission died within 1 year, this was 12% in patients without cancer. In hematological patients, 1-year mortality decreased between 2008 and 2011, after which it stabilized. In solid cancer patients, inspection showed neither an increasing nor decreasing trend over the inclusion period. For patients without cancer, 1-year mortality decreased between 2008 and 2013, after which it stabilized. A clear decrease in hospital mortality was seen within all three groups. Conclusion: The 1-year mortality of cancer patients with an unplanned ICU admission (hematological and solid) was higher than that of patients without cancer. About one-third of the cancer patients surviving their hospital admission died within 1 year after ICU admission. We found a decrease in 1-year mortality until 2011 in hematology patients and no decrease in solid cancer patients. Our results suggest that for many cancer patients, an unplanned ICU admission is still a way to recover from critical illness, and it does not necessarily lead to success in long-term survival. The underlying type of malignancy is an important factor for long-term outcomes in patients recovering from critical illness. [ABSTRACT FROM AUTHOR]

Author(s): Frédéric Pène [sup.1] [sup.2], Dominique D. Benoit [sup.3] Author Affiliations: (1) grid.411784.f, 0000000102743893, Medical ICU, Cochin Hospital, AP-HP, , Paris, France (2) grid.10992.33, 0000000121880914, University Paris Descartes, Sorbonne Paris [...]

Author(s): Katherine R. Courtright [sup.1] [sup.2], Dominique D. Benoit [sup.3], J. Randall Curtis [sup.4] [sup.5] Author Affiliations: (1) 0000 0004 1936 8972, grid.25879.31, Department of Medicine, Perelman School of Medicine, [...]

Patients with acute respiratory distress syndrome (ARDS) have dorsal atelectasis of the lungs. This is probably caused by several mechanisms: compression on dependent lung zones, purulent secretions in alveoli, and [...]

Author(s): Dominique D. Benoit [sup.1] [sup.2], Pieter O. Depuydt [sup.1] [sup.3] Author Affiliations: (1) grid.410566.0, 0000000406263303, Medical Unit, Department of Intensive Care, Ghent University Hospital, , De Pintelaan 185, 12K12IB, [...]

Introduction: Given clinicians' frequent concerns about unfavourable outcomes, Intensive Care Unit (ICU) triage decisions in acutely ill cancer patients can be difficult, as clinicians may have doubts about the appropriateness of an ICU admission. To aid to this decision making, we studied the survival and performance status of cancer patients 2 years following an unplanned ICU admission. Materials and methods: This was a retrospective cohort study in a large tertiary referral university hospital in the Netherlands. We categorized all adult patients with an unplanned ICU admission in 2017 into two groups: patients with or without an active malignancy. Descriptive statistics, Pearson's Chi-square tests and the Mann-Whitney U tests were used to evaluate the primary objective 2-year mortality and performance status. A good performance status was defined as ECOG performance status 0 (fully active) or 1 (restricted in physically strenuous activity but ambulatory and able to carry out light work). A multivariable binary logistic regression analysis was used to identify factors associated with 2-year mortality within cancer patients. Results: Of the 1046 unplanned ICU admissions, 125 (12%) patients had cancer. The 2-year mortality in patients with cancer was significantly higher than in patients without cancer (72% and 42.5%, P <0.001). The median performance status at 2 years in cancer patients was 1 (IQR 0–2). Only an ECOG performance status of 2 (OR 8.94; 95% CI 1.21–65.89) was independently associated with 2-year mortality. Conclusions: In our study, the majority of the survivors have a good performance status 2 years after ICU admission. However, at that point, three-quarter of these cancer patients had died, and mortality in cancer patients was significantly higher than in patients without cancer. ICU admission decisions in acutely ill cancer patients should be based on performance status, severity of illness and long-term prognosis, and this should be communicated in the shared decision making. An ICU admission decision should not solely be based on the presence of a malignancy. [ABSTRACT FROM AUTHOR]

Rationale: Estimating the impact of ventilator-associated pneumonia (VAP) from routinely collected intensive care unit (ICU) data is methodologically challenging.Objectives: We aim to replicate earlier findings of limited VAP-attributable ICU mortality in an independent cohort. By refining statistical analyses, we gradually tackle different sources of bias.Methods: Records of 2,720 adult patients admitted to Ghent University Hospital ICUs (2013-2017) and receiving mechanical ventilation within 48 hours after admission were extracted from linked Intensive Care Information System and Computer-based Surveillance and Alerting of Nosocomial Infections, Antimicrobial Resistance, and Antibiotic Consumption in the ICU databases. The VAP-attributable fraction of ICU mortality was estimated using a competing risk analysis that is restricted to VAP-free patients (approach 1), accounts for VAP onset by treating it as either a competing (approach 2) or censoring event (approach 3), or additionally adjusts for time-dependent confounding via inverse probability weighting (approach 4).Results: A total of 210 patients (7.7%) acquired VAP. Based on benchmark approach 4, we estimated that (compared with current preventive measures) hypothetical eradication of VAP would lead to a relative ICU mortality reduction of 1.7% (95% confidence interval, -1.3 to 4.6) by Day 10 and of 3.6% (95% confidence interval, 0.7 to 6.5) by Day 60. Approaches 1-3 produced estimates ranging from -0.7% to 2.5% by Day 10 and from 5.2% to 5.5% by Day 60.Conclusions: In line with previous studies using appropriate methodology, we found limited VAP-attributable ICU mortality given current state-of-the-art VAP prevention measures. Our study illustrates that inappropriate accounting of the time dependency of exposure and confounding of its effects may misleadingly suggest protective effects of early-onset VAP and systematically overestimate attributable mortality. [ABSTRACT FROM AUTHOR]

Background: Treatment limitation decisions (TLDs) on the ICU can be challenging, especially in patients with a malignancy. Up-to-date literature regarding TLDs in critically ill patients with a malignancy admitted to the ICU is scarce. The aim was to compare the incidence of written TLDs between patients with an active malignancy, patients with a malignancy in their medical history (complete remission, CR) and patients without a malignancy admitted unplanned to the ICU. Methods: We conducted a retrospective cohort study in a large university hospital in the Netherlands. We identified all unplanned admissions to the ICU in 2017 and categorized the patients in 3 groups: patients with an active malignancy (study population), with CR and without a malignancy. A TLD was defined as a written instruction not to perform life-saving treatments, such as CPR in case of cardiac arrest. A multivariate binary logistic regression analysis was used to identify whether having a malignancy was associated with TLDs. Results: Of the 1046 unplanned admissions, 125 patients (12%) had an active malignancy and 76 (7.3%) patients had CR. The incidence of written TLDs in these subgroups were 37 (29.6%) and 20 (26.3%). Age (OR 1.03; 95% CI 1.01 -1.04), SOFA score at ICU admission (OR 1.11; 95% CI 1.05 -1.18) and having an active malignancy (OR 1.75; 95% CI 1.04-2.96) compared to no malignancy were independently associated with written TLDs. SOFA scores on the day of the TLD were not significantly different in patients with and without a malignancy. Conclusions: This study shows that the presence of an underlying malignancy is independently associated with written TLDs during ICU stay. Patients with CR were not at risk of more written TLDs. Whether this higher incidence of TLDs in patients with a malignancy is justified, is at least questionable and should be evaluated in future research. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out‐of‐hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN: Subanalysis of an international multicenter cross‐sectional survey (REAPPROPRIATE). SETTING: Out‐of‐hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS: A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS: The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P =.23); 503 of 564 (89.2%) CPR attempts involved non‐shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non‐shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION: Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39–45, 2019 See related editorial by Monique Anderson Starks [ABSTRACT FROM AUTHOR]

Background: Working in the stressful environment of the Intensive Care Unit (ICU) is an emotionally charged challenge that might affect the emotional stability of medical staff. The quality of care for ICU patients and their relatives might be threatened through long-term absenteeism or a brain and skill drain if the healthcare professionals leave their jobs prematurely in order to preserve their own health. Purpose: The purpose of this review is to evaluate the literature related to emotional distress among healthcare professionals in the ICU, with an emphasis on the prevalence of burnout and compassion fatigue and the available preventive strategies. Methods: A systematic literature review was conducted, using Embase, Medline OvidSP, Cinahl, Web-of-science, PsychINFO, PubMed publisher, Cochrane and Google Scholar for articles published between 1992 and June, 2014. Studies reporting the prevalence of burnout, compassion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare professionals were included, as well as related intervention studies. Results: Forty of the 1623 identified publications, which included 14,770 respondents, met the selection criteria. Two studies reported the prevalence of compassion fatigue as 7.3% and 40%; five studies described the prevalence of secondary traumatic stress ranging from 0% to 38.5%. The reported prevalence of burnout in the ICU varied from 0% to 70.1%. A wide range of intervention strategies emerged from the recent literature search, such as different intensivist work schedules, educational programs on coping with emotional distress, improving communication skills, and relaxation methods. Conclusions: The true prevalence of burnout, compassion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare professionals remains open for discussion. A thorough exploration of emotional distress in relation to communication skills, ethical rounds, and mindfulness might provide an appropriate starting point for the development of further preventive strategies. [ABSTRACT FROM AUTHOR]

Purpose/Objectives: To explore variations in coping with moral distress among physicians and nurses in a university hospital oncology setting. Research Approach: Qualitative interview study. Setting: Internal medicine (gastroenterology and medical oncology), gastrointestinal surgery, and day clinic chemotherapy at Ghent University Hospital in Belgium. Participants: 17 doctors and 18 nurses with varying experience levels, working in three different oncology hospital settings. Methodologic Approach: Patients with cancer were interviewed based on the critical incident technique. Analyses were performed using thematic analysis. Findings: Moral distress lingered if it was accompanied by emotional distress. Four dominant ways of coping (thoroughness, autonomy, compromise, and intuition) emerged, which could be mapped on two perpendicular continuous axes: a tendency to internalize or externalize moral distress, and a tendency to focus on rational or experiential elements. Each of the ways of coping had strengths and weaknesses. Doctors reported a mainly rational coping style, whereas nurses tended to focus on feelings and experiences. However, people appeared to change their ways of handling moral distress depending on personal or work-related experiences and perceived team culture. Prejudices were expressed about other professions. Conclusions: Moral distress is a challenging phenomenon in oncology. However, when managed well, it can lead to more introspection and team reflection, resulting in a better interpersonal understanding. Interpretation: Team leaders should recognize their own and their team members' preferred method of coping and tailored support should be offered to ease emotional distress. [ABSTRACT FROM AUTHOR]