Patients and their surrogates often disagree with clinicians about appropriateness of ICU treatment, leading to lower satisfaction, according to a new study.
Researchers performed a multicenter, prospective, observational study of adult patients at six ICUs in the U.S. and Hungary to determine how often patients or their surrogates perceived treatment to be inappropriate. They also examined the effect of this perception on adverse outcomes, as well as discordance with the opinions of clinicians. Patients, surrogates, physicians, and nurses were surveyed daily during the ICU stay about perceived inappropriate treatment, reasons for perceived inappropriate treatment, and associated distress. In addition, patient and surrogate satisfaction was assessed daily and at ICU discharge, patient and surrogate trust was assessed daily, and patient and surrogate anxiety and depressive symptoms were measured at ICU discharge. The study results were published March 25 by Chest.
The study included 151 patients for whom 1,332 surveys of patients, surrogates, nurses, and physicians were collected. In 8% of patients, patients and surrogates reported too much treatment, and in 6%, they reported too little. Too much treatment was defined as treatment that would not benefit the patient, that caused unnecessary burden, or was contrary to patient wishes, while too little treatment was defined as any additional treatment that the patient should be receiving. Twenty-six percent of patients and surrogates disagreed with clinicians about whether too much treatment was administered, while 10% disagreed about whether too little treatment was administered.
An association was seen between disagreement about perceived inappropriate treatment and both prognostic discordance and lower patient or surrogate satisfaction (P=0.02 for both comparisons). In addition, perceived inappropriate treatment was associated with moderate or high distress in 55% of patient and surrogate respondents and 35% of physician and nurse respondents. Patients and surrogates who perceived inappropriate treatment were more likely to also report lower satisfaction and less trust in the clinical team. However, no statistically significant difference was seen between perception of inappropriate treatment and patient or surrogate depression or anxiety.
The researchers noted that the patients in this study may have been less ill than other populations and that the sample size was small, among other limitations. They concluded that ICU patients and surrogates may often disagree with clinicians regarding appropriateness of treatment and that such disagreements may be linked to disagreements about prognosis and to lower patient and surrogate satisfaction. “Understanding differences in perception of the appropriateness of treatment among patients, family members, and clinicians may play an important role in developing effective interventions to improve communication, satisfaction, and goal concordant treatment,” the authors wrote.