title: A prospective determination of the incidence of perceived inappropriate care in critically ill patients.
abstract: BACKGROUND
  Health care providers' perceptions regarding appropriateness in end-of-life treatments have been widely studied. While nurses and physicians believe that rationing and other cost-related practices sometimes occur in the intensive care unit (ICU), they allege that treatment is often excessive.
  
  
  OBJECTIVE
  To prospectively determine the incidence and causes of health care providers' perceptions regarding appropriateness of end-of-life treatments.
  
  
  METHODS
  The present prospective study collected data from patients admitted to the medical-surgical trauma ICU of a 30-bed, Canadian teaching hospital over a three-month period. Daily surveys were completed independently by bedside nurses, charge nurses and attending physician.
  
  
  RESULTS
  In total, 5224 of 6558 expected surveys (representing 294 patients) were analyzed, yielding a response rate of 79.7%. The incidence of perceived inappropriate care in the present study was 6.5% (19 of 294 patients), with ongoing treatment for >2 days after this determination occurring in 1% (three of 294 patients). However, at least one caregiver perceived inappropriate care at some point in 110 of 294 (37.5%) patients. In these cases, in which processes to address care were not already underway, respondents believed that important issues resulting in provision of inappropriate treatments included patient-family issues and communication before or in the ICU. Caregivers did not know their patients' wishes 22% (1129 of 5224) of the time.
  
  
  CONCLUSIONS
  Although ongoing inappropriate care appeared to be a rare occurrence, the issue was a concern to at least one caregiver in one-third of cases. Public awareness for end-of-life issues, adequate communication, and up-to-date knowledge and practice in determining the wishes of critically ill patients are potential target areas to improve end-of-life care and reduce inappropriate care in the ICU. A daily, prospective survey of multidisciplinary caregivers, such as the survey used in the present study, is a viable and valuable means of determining the scope and causes of inappropriate care in the ICU.
authors.forename: Rohit K
authors.initials: RK
authors.lastname: Singal
authors.forename: Robert
authors.initials: R
authors.lastname: Sibbald
authors.forename: Brenda
authors.initials: B
authors.lastname: Morgan
authors.forename: Mel
authors.initials: M
authors.lastname: Quinlan
authors.forename: Neil
authors.initials: N
authors.lastname: Parry
authors.forename: Michael
authors.initials: M
authors.lastname: Radford
authors.forename: Claudio M
authors.initials: CM
authors.lastname: Martin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D003422:Critical Care / Q000379:methods* / Q000706:statistics & numerical data; D016638:Critical Illness; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009864:Ontario; D011446:Prospective Studies; D013727:Terminal Care / Q000379:methods* / Q000706:statistics & numerical data; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*