© 2003 American Thoracic Society
Perceptions, ConfessionsA Systems Response Is NeededPulmonary and Critical Care Divisions Department of Medicine LDS Hospital and University of Utah School of Medicine Salt Lake City, Utah Human limitations interfere with consistent and rational decision-making (1, 2). Clinical decision-makers are faced with frequent information overload that further impedes consistent decision-making. Add to these two observations the moral, ethical, and clinical challenges and uncertainties associated with the clinical management of terminal critical illness, and we have multiple opportunities for intellectual misbehavior in the intensive care unit (ICU) environment. Inadequate care of dying patients has been documented (3, 4). We have been disappointed by the absence of significant improvement after educational efforts to address this inadequate care. In addition, some nurses have admitted engaging in euthanasia, sometimes without a physician's order (5). It is clear that the health care delivery system contains elements of behavior that foster mistrust among patients and their families, and that foster misbehavior among some clinicians. Results of published studies suggest that interdisciplinary collaboration in the ICU improves clinical outcomes. Certainly such collaboration has face validity and seems eminently reasonable. Supporting this conclusion is the observation that satisfaction of clinical staff with decision-making is associated with clinical outcome. Interestingly, nurses' but not physicians' perceptions of collaboration are associated with clinical outcome. This suggests that nurses are better reflectors of ICU clinician collaboration than are physicians—another observation that has face validity. This said, there are few studies and precious little data to support conclusions that ICU clinician collaboration leads to better clinical outcomes for the dying patient. In this issue of AJRCCM (pp. 1310–1315), Ferrand and colleagues (6) report observations on several important issues associated with the decision to forego life-sustaining treatments. They collected questionnaire data from clinicians in 133 French-speaking ICUs in Europe (42% of 320 ICUs surveyed). Two-thirds were medical–surgical ICUs and the remainder evenly distributed between surgical and medical ICUs. ICUs were included if at least 10% of their personnel returned completed questionnaires. Among the 133 included ICUs, however, only 50% of responding nurses and 57% of physicians answered more than 90% of the questions. Therefore, about 21% of all staff members in the 320 ICUs screened (half of 42%) submitted completed questionnaires (more than 90% questions answered). Although this is an under-representation of the clinicians in all the screened ICUs, and therefore raises legitimate questions about external validity, it seems an adequate sample for the authors' purposes. Nurses provided 2,875 and physicians provided 521 completed questionnaires. Importantly, 91% of nurses and 99% of physicians who submitted completed questionnaires had previous experience with decisions to forego life-sustaining treatments. The reported results are, therefore, quite meaningful. Ferrand and colleagues (6) report nursing dissatisfaction with the process of decisions about foregoing life-sustaining treatments that far exceeds physician dissatisfaction. Marked differences between nurse and physician perceptions were observed. Although physician satisfaction with decisions to forego life-sustaining treatments was 73%, only 33% of nurses were satisfied with such decisions. Interestingly, satisfaction was higher (82%) among medical ICU nurses. Almost all respondents agreed that a sound collaborative process for making decisions to forego life-sustaining treatments was important and needed to be done, but the execution of this commitment fell far short of the agreed goal. Only five ICUs had written policies for making decisions to forego life-sustaining treatments. This points to the need for a systematic, or systems, response to support clinical decision-makers. Guidance is needed from professional organizations, legal agencies, ethical groups, and from locally adopted or generated guidelines and protocols. Ferrand and colleagues (6) remind us that, unlike the United States where patient surrogates make decisions for incompetent patients in ICU, in Europe physicians perform that function. European physicians receive little formal guidance in making decision to forego life-sustaining treatments. Fear of litigation had a negative impact on physician behavior when making decisions to forego life-sustaining treatments. Physicians admitted (Table 8 of reference 6) modifying information given to patients (7%), to patient families (15%), and to nurses (5%). Ferrand and colleagues (6) courageously report in their Discussion physician-dissembling rates of 20–50%. Physicians also admitted modifying the amount of information included in their medical notes. Seventeen percent of physicians (in contrast, 58% in their Results: Liability) reported that their notes on decisions to forego life-sustaining treatments were inaccurate. Both nurses (31%) and physicians (39%) believed that families should not be fully informed. All of these reported frequencies are important findings. Intentional misrepresentation to patients, families, and nurses, and dissembling in medical notes are warnings that something is seriously awry. Such behavior will likely have a corrosive effect on fundamental relationships in the ICU, in the health care delivery system, and within society at large. A societal response with medical, ethical, and legal contributions is necessary. I believe that medical professional societies are best equipped to take the lead in this matter. Ferrand and colleagues (6) have contributed to the articulation of the problems of dissatisfaction, misrepresentation, and dissembling that are present within the complex set of ethical, medical, financial, legal, and administrative imperatives, pressures, and constraints that abound in the ICU process of making decisions to forego life-sustaining treatments. I believe this contribution is sound, despite the scientific shortcomings of their study. Their survey consisted of closed-ended questions tested on two ICU clinician groups to assure appropriateness of the responses. The authors recognize the potential for bias (7) in such an instrument. They evaluated perceptions of the participating clinicians. It is well known that perceptions are frequently inadequate reflections of behavior (8). The reported results may therefore be inaccurate regarding performance or experience of the individual respondents. It is perception rather than truth, however, that motivates much human decision-making and action. Therefore, the identification of perceptions is, for the purposes of this study, quite satisfactory. It does not seem crucial to me that the reported frequencies of responses may not accurately reflect the entire population of clinicians in all 320 screened ICUs. The study population is sizeable enough and is a large enough fraction of all possible respondents to have credibility. Although not proved, their results support the conclusion that nurses are better sensors of collaboration in the ICU than are physicians. Their results should lend support to organized efforts to address the challenges of terminal care of the critically ill. REFERENCES
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