Outcomes of ICU patients with and without perceptions of excessive care:a comparison between cancer and non-cancer patients

BACKGROUND: Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer.METHODS: This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer.RESULTS: Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p &lt; 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60-1.72 and HR 0.87, 95% CI 0.49-1.54) and TLDs (HR 0.81, 95% CI 0.33-1.99 and HR 0.70, 95% CI 0.27-1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58-3.15 and 1.66, 95% CI 1.28-2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups.CONCLUSIONS: The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.</p

Outcomes of ICU patients with and without perceptions of excessive care:a comparison between cancer and non-cancer patients

BACKGROUND: Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer.METHODS: This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer.RESULTS: Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p &lt; 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60-1.72 and HR 0.87, 95% CI 0.49-1.54) and TLDs (HR 0.81, 95% CI 0.33-1.99 and HR 0.70, 95% CI 0.27-1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58-3.15 and 1.66, 95% CI 1.28-2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups.CONCLUSIONS: The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.</p

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

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

Clinical studies of calcium metabolism in essential hypertension

Many factors can ultimately lead to an increased blood pressure and it is a generally accepted view that an increase in the active tension of arterioles reflects an increase of the free calcium concentration in the cytosol of the vascular smooth muscle cells. Only recently, however, has the possibility been considered that blood pressure regulation could be influenced by calcium homeostasis. A background for these studies has been provided by the epidemiological observations which link hypertension to a low dietary intake of calcium as well as experimental studies in animals, mostly rats, which have demonstrated that various disturbances of calcium metabolism are related to a raised blood pressure. This review is focused on clinical studies of a possible association between systemic calcium metabolism and the regulation of blood pressure

Indices of mineral metabolism in subjects with an impaired glucose tolerance

An altered mineral metabolism has been described both in insulin dependent and non-insulin dependent diabetes mellitus. In order to investigate if a disturbed mineral homeostasis was an early feature in the development of diabetes, 52 middle-aged men who all had recently developed an impaired glucose tolerance (IGT) were compared to healthy control persons. The IGT subjects showed higher levels of serum calcium (2.38 +/- 0.081 mmol/l (SD) vs 2.35 +/- 0.065 in controls) but similar levels of plasma ionized calcium indicating an increased protein binding of serum calcium in IGT. Serum magnesium was significantly lower in the IGT subjects (0.79 +/- 0.060 mmol/l vs 0.85 +/- 0.065, p less than 0.001) while serum phosphate was unaltered. This study demonstrates indices of an impaired mineral metabolism in IGT subjects similar in characteristics to what has previously been reported in manifest diabetes mellitus suggesting that an alteration of mineral homeostasis could be part of a primary event

Interactions between indices of calcium metabolism and blood pressure during calcium infusion in humans

Calcium plays a central role in maintaining vascular tone. Recent studies indicate that there are continuous relationships between systemic calcium metabolism and BP, as over the whole range of normal and raised BPs there is an inverse correlation between plasma ionised calcium concentration and BP. Twenty-two subjects with normal or moderately elevated BP participated in the present study, undertaken to investigate the interactions between systemic calcium metabolism and BP during a two-hour constant-rate calcium infusion in the absence and in the presence of concomitant verapamil infusion. During the infusion there was an increase in plasma ionised calcium by 0.40 mmol/l, SBP rose by 14 mmHg, and DBP by 9.7 mmHg. Higher basal plasma ionised calcium and lower basal serum parathyroid hormone concentrations were associated with a more pronounced diastolic pressor response to the calcium infusion. A greater DBP increase was also accompanied by more pronounced parathyroid hormone suppression, determined as cyclic adenosine monophosphate excretion, and greater tissue uptake of calcium during the infusion. Conversely, higher basal BPs were associated with greater tissue calcium uptake during the infusions. This relationship was abolished when verapamil was present. The present findings extend the previous observations of continuous relationships between indices of calcium metabolism and BP and indicate that both a direct effect of the calcium ion and indirect effects, as evidenced by cyclic adenosine monophosphate excretion, affect the BP response to acute hypercalcaemia