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

Symulacja numeryczna płynięcia turbulentnego w warstwie ścinanej

For various problems of continuum mechanics described by the equations of hyperbolic type, the comparative analysis of scenarios of development of turbulent flows in shear layers is carried out. It is shown that the development of the hydrodynamic instabilities leads to a vortex cascade that corresponds to the development stage of the vortices in the energy and the inertial range during the transition to the turbulent flow stage. It is proved that for onset of turbulence the spatial problem definition is basic. At the developed stage of turbulence the spectral analysis of kinetic energy is carried out and the Kolmogorov “-5/3” power law is confirmed.W pracy dokonano analizy porównawczej rozwoju przepływu turbulentnego w warstwach ścinanych dla wielu problemów dotyczących mechaniki ośrodków ciągłych opisanych przez równania typu hiperbolicznego. Wykazano, że rozwój niestabilności hydrodynamicznych prowadzi do cyklicznych zawirowań podczas przejścia do stadium przepływu turbulentnego. Udokumentowano, że dla wyjaśnienia mechanizmu pojawienia się turbulencji kluczowe znaczenie ma przestrzenna analiza problemu. Przeprowadzono analizę widmową energii kinetycznej dla zaawansowanego stadium przepływu turbulentnego oraz potwierdzono wartość wykładnika “-5/3” w równaniu Kołmogorowa