Predictors of clinician discomfort with daily life support plans for mechanically ventilated patients

Objective

To examine the incidence and predictors of clinician discomfort about daily advanced life support plans for ICU patients.

Design

Prospective international cohort study.

Setting

Thirteen university-affiliated ICUs in Canada, the United States, Australia and Sweden.

Patients

Six hundred and thirty-three mechanically ventilated adults with an expected ICU length of stay of 72 hours or more.

Measurements

We documented the daily plan for advanced life support and asked the bedside nurse, ICU resident and physician how comfortable they were with this plan. If they were uncomfortable, they stated whether the plan was too technologically intense or not intense enough, and why. We used hierarchical logistic regression to examine predictors of discomfort.

Results

Of 15,800 observations, 1294 (8.2%) indicated discomfort with the life support plan. At least one clinician was uncomfortable on at least one occasion for 295 (46.6%) patients. Discomfort occurred more often when the plan was too intense than when the plan was not intense enough (94.7% vs 5.3%, P < 0.001). We found the following factors independently predicted discomfort because the plan was too intense: patient age (odds ratio [OR] 1.19, 95% CI 1.07–1.33 for 10 year intervals), APACHE II score (OR 1.23, 1.09–1.38 for five-point intervals), medical admission (OR 2.66, 1.65–4.29), poor prior functional status (OR 3.52, 1.98–6.26 compared with good functional status), daily organ dysfunction (OR 1.60, 1.25–2.04 for each five-point interval), dialysis in the ICU (OR 3.09, 2.05–4.66), plan to withhold dialysis (OR 2.03, 1.52–2.70), plan to withhold mechanical ventilation (OR 0.20, 0.06–0.65), first week in the ICU (OR 1.76, 1.40–2.22), clinician (OR 1.92, 1.75–2.10 for nurse versus resident and OR 1.57, 1.43–2.1 for attending physician versus resident), and city.

Conclusions

Clinicians often experience discomfort about life support plans for mechanically ventilated patients. Discomfort occurs more often among nurses and is more likely for older, more severely ill medical patients developing acute renal failure, and for extubated patients for whom there are no plans to withhold ventilation.