PURPOSE: Whether 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. METHODS: In 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. RESULTS: Of 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. CONCLUSION: Enhancing 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.

Department of Anaesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden

Department of Anesthesia Critical Care and Pain Medicine Beth Israel Deaconess Medical Center and Harvard Medical School Boston MA USA

Department of Anesthesiology and Intensive Care 1st Faculty of Medicine Charles University Prague and General University Hospital Prague Prague Czech Republic

Department of Applied Mathematics Computer Science and Statistics Faculty of Sciences Ghent University Ghent Belgium

Department of Geriatric Medicine Ghent University Hospital Ghent Belgium

Department of Intensive Care Medicine Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands

Department of Intensive Care Medicine Ghent University Hospital Corneel Heymanslaan 10 Ghent Belgium

Department of Intensive Care Medicine Vejle Hospital Vejle Denmark

Department of Medical Oncology University of Groningen University Medical Center Groningen Groningen The Netherlands

Department of Psycho analysis and Clinical Consulting Faculty of Psychology and Educational Sciences Ghent University Ghent Belgium

Hôpital Saint Louis and University Paris 7 Paris France

Institute of Regional Research University of Southern Denmark Odense C Denmark

Intensive Care Department Hospital S António Porto Portugal

King's College Hospital London UK

London School of Hygiene and Tropical Medicine London UK

SCDU Anestesia e Rianimazione Azienda and Ospedaliero Universitaria Maggiore della Carità Novara Italy

Semmelweis University Budapest Budapest Hungary

Service des soins intensifs et urgences oncologiques Institut Jules Bordet ULB Brussels Belgium

Tettnang Hospital Tettnang Germany

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