Observational studyIntensive care medicine2018
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.
Observational study in Intensive care medicine, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to 2 registered trials, which are not on this map. Cited by 51 papers, 3 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Coaching Doctors to Improve Ethical Decision-making in Adult Hospitalized Patients Potentially Receiving Excessive Treatment: a Step Wedge Cluster Randomized Trial in 10 Departments of the Ghent University Hospital (CODE)
Coaching Doctors and Nurses to Improve Ethical Decision-making in Team: a Stepped Wedge Cluster Randomized Trial in 10 Departments of the Ghent University Hospital
Who cites it
51 citing papers in PubMed, 3 syntheses or guidelines pooled it, 134 citations in OpenAlex.
- Goals of care discussions in hospitalised patients: systematic review of randomised trials.BMJ supportive & palliative care · 2026Pooled it
- Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis.Intensive care medicine · 2020Pooled it
- Changes in critically ill cancer patients' short-term outcome over the last decades: results of systematic review with meta-analysis on individual data.Intensive care medicine · 2019Pooled it
- Discussing expected long-term quality of life in the ICU: effect on experiences and outcomes of patients, family, and clinicians-a randomized clinical trial.Intensive care medicine · 2025Trial
- Trial
- Coaching doctors to improve ethical decision-making in adult hospitalized patients potentially receiving excessive treatment. The CODE stepped-wedge cluster randomized controlled trial.Intensive care medicine · 2024Trial
- Swedish Intensive Care Physicians' Attitudes Towards Withholding or Withdrawing Life-Sustaining Treatment in Critically Ill Children.Acta anaesthesiologica Scandinavica · 2026Article
- Physicians and relatives facing end-of-life decisions in intensive care: ethical insights from a comparison of French and American models.BMC medical ethics · 2026Article
- [Ethically challenging determination of treatment goals in the intensive care unit: reasons, frequency and possible solutions].Die Anaesthesiologie · 2026Review
- The role of timely assessment of appropriate care in reducing greenhouse gas emissions in intensive care medicine.Annals of intensive care · 2026Article
- [S1 guideline on sustainability in intensive care and emergency medicine].Medizinische Klinik, Intensivmedizin und Notfallmedizin · 2025Review
- Article
- Perceptions of ethical decision-making climate among clinicians working in European and US ICUs: differences between religious and non-religious healthcare professionals.BMC medical ethics · 2025Observational
- Goals of care discussions and treatment limitation decisions in European acute geriatric units: a one-day cross-sectional study.Age and ageing · 2025Article
- [Intensive care and emergency medicine overuse and sustainability].Medizinische Klinik, Intensivmedizin und Notfallmedizin · 2025Review
- Triggers of intensive care patients with palliative care needs from nurses' perspective: a mixed methods study.Critical care (London, England) · 2024Article
- Family centeredness of care: a cross-sectional study in intensive care units part of the European society of intensive care medicine.Annals of intensive care · 2024Article
- Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit.Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine · 2024Article
- Negativity and Positivity in the ICU: Exploratory Development of Automated Sentiment Capture in the Electronic Health Record.Critical care explorations · 2023Observational
- Simplified Legal Procedure for End-of-life Decisions in India: A New Dawn in the Care of the Dying?Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine · 2023Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
23 authors at 11 institutions in 11 countries.
Funding
Abstract
purposeWhether 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.
methodsIn 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.
resultsOf 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.
conclusionEnhancing 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.
Indexed as
Identifiers
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.