The Problem of Disproportionate Critical Care
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Francesca Rubulotta talks about disproportionate care in ICU. Disproportionate care is disproportionate in relation to the expected prognosis. Moreover, this can lead to moral distress among clinicians who think they are offering inappropriate care. There is mounting research and evidence pointing to the existence of disproportionate care. Furthermore, stress and burnout cause increased miscommunication and lead to low performance and concentration. Stress leads to absenteeism or in many cases, presenteeism. Presenteeism is when someone just shows up for work but does the bare minimum. Francesca shows the financial burden caused by absenteeism across various countries. Francesca points out that only 14% of employees feel engaged in their jobs. Moreover, data shows that companies which keep their employees engaged have higher rates of performance. Such companies have managers who are more engaged and approachable. Francesca discusses various studies that look at the appropriateness of care in ICU. She talks about the CONFLICUS, APPROPRICUS and DISPROPICUS studies, all of which point to the moral stress experienced when clinicians are forced to give inappropriate care. We must ask whether inappropriate care occurred and why. The three major factors influencing the perception of inappropriate care are client related situations, work characteristics and personal characteristics. 27% of healthcare providers (HCP) report at least one of their patients are mismanaged per day. Furthermore, 63% say that inappropriate care happens all the time. There are multiple reasons for disproportionate care taking place. Studies show that nurses associated inappropriate care to interpersonal factors while physicians ascribed it to prognostic uncertainty. Francesca discusses the methods used and results obtained in the DISPROPICUS study and self-awareness and individual development in ICU. According to her, these future studies will help to find solutions to the problems regarding disproportionate care. Evidently, authentic leaders, who can inspire others, are the need of the hour. For more like this, head to our podcast page. #CodaPodcast
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The Problem of Disproportionate Critical Care
- 1. Francesca Rubulotta MD, PhD, FRCA,FFICM, Chair of the Division of Professional Development of the ESICM UEMS/EACCME Governance board EBICM member Centre for Perioperative Medicine & Critical Care Research Imperial College Healthcare NHS Trust
- 2. The Problem of Disproportionate Critical Care Dublin 2016
- 4. Disclosure • No Conflict of Interests
- 5. • Background • Appropriateness of care in ICU • Future studies • Conclusions
- 6. • Background • Appropriateness of care in ICU • Future studies • Conclusions
- 7. Definition: care which is perceived by health care providers as disproportionate in relation to the expected prognosis in terms of survival or quality of life. ‘Disproportionate care’
- 8. Clinicians who perceive the care they provide as inappropriate experience moral distress and are at risk for burnout.
- 9. Do we provide Disproportionate care?
- 10. ESICM executive commitee meeting 10Bruxelles 15-16/ 11 /2011 The number of published studies related to burnout, conflicts, moral distress is dramatically increasing. The Evidence
- 11. The evidence … Did you ever experience a day like this…
- 12. ESICM executive commitee meeting 12Bruxelles 15-16/ 11 /2011 Does it have an impact? • Stress, conflicts and burnout are proven to impair communication among the ICU staff • There is evidence suggesting that the burnout leads to low performance and concentration.
- 13. Workplace-related stress & absenteeism: a European priority
- 14. Scale & Costs of absenteeism • EU: The European Foundation for the Improvement of Living and Working Survey, 2004, 2009 and 2013 : – The 29% of workers believe that their work affects their health. • Depression 38% – Matrix (2013), the cost to Europe of work- related depression was estimated to be 617 billion /year (absenteeism €272 b)
- 15. Scale & Costs of absenteeism • UK’s estimated cost of stress, depression and anxiety (the Health and Safety executive 2010/11) –3,6 billion pounds/year –1 in 3 employees has interpersonal conflict at work (the Chartered Institute of Personnel and Development, 2015)
- 16. Scale & Costs of absenteeism • USA: 54% stress-related (Harris et al., Elkin & Rosch) –500 billion dollars/yr, • Canada: cost of work-related stress in Canada –CA$11 billion. • Australia estimated the costs absenteeism due to work-related stress (Econtech 2008) –$14.81 billion /year ???
- 17. Scale & Costs of absenteeism • Italy:
- 18. Job VS profession concept! Only 14% MILLENNIUM employees are engaged in their job (Gallup 2016, American research-based, global performance-management consulting company) DOCTORS VS EMPLOYEES
- 19. 19 The Current Concept of Work-life balance Craig Carr P Gruber, et al. ATCIC:Management in Intensive Care
- 20. Ideal work-life balance Does having a successful, demanding, time consuming career necessarily result in deterioration of your private life? Work-life conflicts Work-life enrichments Shankar and Batnagar (2010)
- 22. • Is your workplace productive?86% of employees worldwide are not engaged. Many companies are experiencing a crisis of engagement and aren't aware of it. • COMPANIES WITH HIGHLY ENGAGED WORKFORCES OUTPERFORM THEIR PEERS BY 147%
- 25. • Background • Appropriateness of care in ICU • Future studies • Conclusions
- 26. 26 ESICM Studies CONFLICUS: Azoulay E, Am J Respir Crit Care Med. 2009 APPROPRICUS Piers R, Benoit D et al. JAMA 2011 DISPROPRICUS Benoit D et al 2013- 2015
- 27. Single-day cross-sectional study The APPROPRICUS STUDY APPROPRIATENESS of CARE in the ICU’s
- 28. Definition of ‘inappropriate care’ in this study a specific patient-care situation in which the provider acts in a manner contrary to his/her personal and professional beliefs ~ Definition of ‘Moral Distress’ occurs when the healthcare provider feels certain of the ethical course of action but is constrained from taking that action
- 29. Aim / Research questions – What is the prevalence of the perception of inappropriate care among ICU healthcare providers (nurses and physicians)? – Which are the patient-related situations evoking this perception? – Which are the factors associated with it?
- 30. d situation: age, co-morbidities, … Work characteristics •End of life decision involvement •Jobstrain •(demand, control, support) •Collaboration •Ethical climate Personal characteristics •Demographic characteristics •Role: nurse - physician
- 31. tient-related situation Moral Distress (ACUTE stress) Work characteristics sonal characteristics Perception of Inappropriate care Burnout (CHRONIC stress) ↓ Quality of patient care
- 32. Method: – Single-day cross-sectional study – Self-report survey (paper) May 11th 2010 Note: different shifts
- 33. Results: –ICUs in 10 European countries –99 ICUs, 17 no IRB 82 Reported –ADULT patients (> 16 years old) –1691 Healthcare providers (HCPs) • nurses (head nurses, nurses and nurse assistants) • physicians (junior and senior) –Responders rate median 93%
- 35. Prevalence of perceived inappropriate care – 27% (439/1651*) of HCP found that care was inappropriate for at least one of their patients – How often do similar situations occur in you ICU? (63% often)
- 36. Prevalence of perceived inappropriate care – 27% (439/1651*) of HCP found that care was inappropriate for at least one of their patients To what extend are you confident that inappropriate care in this patient will be resolved in your ICU? (57% are not confident)
- 39. Jobleave – 9% of respondents left previous jobs because of dissent with the way patient care was handled – 31% of respondents had thoughts about leaving their current job • 28% in respondents not indicating inappropriate care • 39% in respondents indicating inappropriate care (Chi-Square, p<0.001)
- 40. Gallup Daily tracking, • 32% of employees in the U.S. are engaged • Worldwide, only 13% of employees working for an organization are engaged. • 24% are "actively disengaged,"
- 41. Factors associated Hierarchical Multivariate Regression analysis Healthcare providers reporting •That nurses are not involved in the EOL decision- making •Poor nurse physician collaboration •Not having freedom how to do their work •Perception of having to work very hard
- 42. Factors associated with the perception of inappropriate care Hierarchical Multivariate Regression analysis
- 43. Conclusions • 1 in 4 ICU healthcare providers perceived that at least one of their patients was getting inappropriate care on the day of the survey • 63% stated that similar situations often occur • 57% didn’t believe this would be resolved
- 44. Conclusions • Providing ‘too much care’ is the most frequent situation evoking this perception of inappropriate care • followed by the daily pressure of shortage of ICU beds. (‘other patients would benefit more’)
- 45. Conclusions Interventions aimed at improving the quality of the nurse- physician collaboration are important
- 46. Conclusions • Clinicians who perceive the care they provide as inappropriate experience moral distress and are at risk for burnout. • This situation may jeopardize patient quality of care and increase staff turnover.
- 47. Mechanisms underlying inappropriate care in European ICUs: confronting views from nurses, junior and senior physicians Chest 2014, Aug;146(2):267-75
- 48. • Distress related to perceived inappropriate care was most common in nurses. • Nurses associated a higher workload with a higher rate of perceived inappropriate care.
- 49. • Junior physicians had the lowest rates of distress related to perceived inappropriate care. • Physicians more often ascribed inappropriate care to prognostic uncertainty and nurses to interpersonal factors
- 50. • Background • Appropriateness of care in ICU • Future studies • Conclusions
- 51. The DISPROPRICUS STUDY Disproportionate care in the ICU’s : a multicenter international longitudinal study Supported by the Ethics section of ESICM. Grant : ECCRN clinical research award 2012.
- 52. Definition of ‘disproportionate care’ care which is perceived by health care providers as disproportionate in relation to the expected prognosis in terms of expected survival or quality of life. ~ Definition of ‘Moral Distress’ occurs when the healthcare provider feels certain of the ethical course of action but is constrained from taking that action
- 54. Currently 74 units in 61 hospitals in 12 countries
- 55. The DISPROPRICUS STUDY Milan Italy, ESICM 2016 frubulotta@hotmail.com francesca.rubulotta@imperial.nhs.uk .
- 56. Bruxelles 15-16/ 11 /2011 ESICM executive commitee meeting 58 ESICM SAID in ICU Self-awareness and individual development in ICU • frubulotta@hotmail.com francesca.rubulotta@imperial.nhs.uk
- 57. 59 “The project is addressed to nurses and doctors working in the ICU. The idea is to allow doctors and nurses to have a personal development course and more self-awareness,
- 59. We all have the capacity to inspire and empower others… But we must first be willing to devote ourselves to our personal growth and development as leaders.
- 60. Contrary to the opinion of many people, leaders are not born Leaders are made, and they are made by effort and hard work. Vince Lombardi, professional football coach
- 63. Authentic Leaders VS Managers “The story of your life is not your life. It is your story.” In other words, it is your personal narrative that matters, not the mere facts of your life John Barth
- 64. • Background • Appropriateness of care in ICU • Future studies • Conclusions
- 65. Conclusions • Conflicts and disproportional care reduce quality of care in ICU • Increasing awareness of the problem/s • No interventions planned
- 67. CIAO Thank you
Editor's Notes
- Report for the European Commission 2002 Directorate-General for Employment and Social Affairs, Unit D.5 European Research on Work-related StressEuropean Agency for Safety and Health at Work 2000. Cox T et al. Institute of Work, Health & Organisations, University of Nottingham Business Schoolhttp://osha.europa.eu/research/rtopics/stress/stress.asp?tcid=3&redirpopup=1
- The Sainsbury Centre for Mental Health (2007) estimated that sickness absence due to stress, anxiety and depression costs British society approximately £1.26 billion a year4. This figure was obtained by multiplying the average duration, in days, of work-related illness absences by the daily absence cost and the total number of episodes of absence. Chandola (2010) used data from 2001/02 indicating that 35 % of self-reported health complaints are due to stress, anxiety or depression. This percentage was then applied to the Health and Safety Executive’s (HSE) cost of work-related ill-health and accidents in 2001/02 of £20–36 billion a year. This deductive approach resulted in a cost for work-related stress of between £7 and £10 billion for 2001/02, equivalent to 0.7–1.2 % of the country’s GDP. 4 Appendix II presents the adjusted euro equivalents of the costs calculated in non-euro currencies European Agency for Safety and Health at Work – EU-OSHA 9Calculating the costs of work-related stress and psychosocial risks – A literature review In 2010/11, the Health and Safety executive (HSE, 2010/11) conservatively estimated the cost of stress, depression and anxiety at £3.6 billion. This was based on an estimated cost of one case (£16 400) multiplied by the reported number of cases of ‘stress, depression and anxiety’ (222 000). This is the total cost incurred by individuals, employers and the government, and includes health care and rehabilitation costs, costs resulting from disruption of production, loss of income, and administrative and legal costs. Giga et al. (2008) examined how the use of different analytical approaches might affect the estimated final cost of workplace harassment. They first adjusted for inflation Beswick and colleagues’ (2006) estimated costs of work-related stress from 1995/96 to obtain an estimated figure of £4.55 billion for 2007. As research has shown that harassment accounts for between 10 % and 20 % of the costs for work-related stress, the median estimate of 15 % was used to determine a figure for the cost of workplace harassment in the UK of £682 million a year. Applying the same figure of 15 % to the cost of stress-related absence only, the total annual cost of which is £1.33 billion, resulted in a cost of harassment-related absence of £199 million. A second deductive approach was based on the previous finding by Gordon and Risley (1999, quoted in Giga et. al. 2008) suggesting that the cost of harassment in the UK is between 1.4 % and 2 % of GDP. Applying a conservative figure of 1.5 % to the UK economy shows that the cost of harassment may, in fact, be as high as £17.65 billion annually. And finally, using an inductive approach, Giga et al. (2008) estimated the costs of harassment-related absence (number of lost days median daily wage), staff turnover (number of harassment-related resignations average cost of replacement) and loss of productivity (number of workers working weeks median weekly salary productivity loss). Summing the individual totals of £3.06 billion, £1.55 billion and £9.14 billion gives an estimated total cost of harassment of £13.75 billion annually. Consequently, Giga and colleagues (2008) were able to provide three figures ranging from £682 million to £17.65 billion, the latter being more than 25 times the former.
- The Sainsbury Centre for Mental Health (2007) estimated that sickness absence due to stress, anxiety and depression costs British society approximately £1.26 billion a year4. This figure was obtained by multiplying the average duration, in days, of work-related illness absences by the daily absence cost and the total number of episodes of absence. Chandola (2010) used data from 2001/02 indicating that 35 % of self-reported health complaints are due to stress, anxiety or depression. This percentage was then applied to the Health and Safety Executive’s (HSE) cost of work-related ill-health and accidents in 2001/02 of £20–36 billion a year. This deductive approach resulted in a cost for work-related stress of between £7 and £10 billion for 2001/02, equivalent to 0.7–1.2 % of the country’s GDP. 4 Appendix II presents the adjusted euro equivalents of the costs calculated in non-euro currencies European Agency for Safety and Health at Work – EU-OSHA 9Calculating the costs of work-related stress and psychosocial risks – A literature review In 2010/11, the Health and Safety executive (HSE, 2010/11) conservatively estimated the cost of stress, depression and anxiety at £3.6 billion. This was based on an estimated cost of one case (£16 400) multiplied by the reported number of cases of ‘stress, depression and anxiety’ (222 000). This is the total cost incurred by individuals, employers and the government, and includes health care and rehabilitation costs, costs resulting from disruption of production, loss of income, and administrative and legal costs. Giga et al. (2008) examined how the use of different analytical approaches might affect the estimated final cost of workplace harassment. They first adjusted for inflation Beswick and colleagues’ (2006) estimated costs of work-related stress from 1995/96 to obtain an estimated figure of £4.55 billion for 2007. As research has shown that harassment accounts for between 10 % and 20 % of the costs for work-related stress, the median estimate of 15 % was used to determine a figure for the cost of workplace harassment in the UK of £682 million a year. Applying the same figure of 15 % to the cost of stress-related absence only, the total annual cost of which is £1.33 billion, resulted in a cost of harassment-related absence of £199 million. A second deductive approach was based on the previous finding by Gordon and Risley (1999, quoted in Giga et. al. 2008) suggesting that the cost of harassment in the UK is between 1.4 % and 2 % of GDP. Applying a conservative figure of 1.5 % to the UK economy shows that the cost of harassment may, in fact, be as high as £17.65 billion annually. And finally, using an inductive approach, Giga et al. (2008) estimated the costs of harassment-related absence (number of lost days median daily wage), staff turnover (number of harassment-related resignations average cost of replacement) and loss of productivity (number of workers working weeks median weekly salary productivity loss). Summing the individual totals of £3.06 billion, £1.55 billion and £9.14 billion gives an estimated total cost of harassment of £13.75 billion annually. Consequently, Giga and colleagues (2008) were able to provide three figures ranging from £682 million to £17.65 billion, the latter being more than 25 times the former.
- In 1936, Gallup successfully predicted that Franklin Roosevelt would defeat Alfred Landon for the U.S. presidency the Literary Digest poll was also one of the largest and most expensive polls ever conducted, with a sample size of around 2.4 million people! At the same time the Literary Digest was making its fateful mistake, George Gallup was able to predict a victory for Roosevelt using a much smaller sample of about 50,000 people. WASHINGTON, D.C. -- Only 13% of employees worldwide are engaged at work, according to Gallup&apos;s new 142-country study on th (ecross 19 Western European countries, 14% of employees are engaged,) State of the Global Workplace. In other words, about one in eight workers -- roughly 180 million employees in the countries studied -- are psychologically committed to their jobs and likely to be making positive contributions to their organizations. The bulk of employees worldwide -- 63% -- are &quot;not engaged,&quot; meaning they lack motivation and are less likely to invest discretionary effort in organizational goals or outcomes. And 24% are &quot;actively disengaged,&quot; indicating they are unhappy and unproductive at work and liable to spread negativity to coworkers. In rough numbers, this translates into 900 million not engaged and 340 million actively disengaged workers around the globe.
- Prevalence and Factors of Intensive Care Unit Conflicts The Conflicus Study. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, 5,268 (71.6%) respondents. Nurse–physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process.
- To determine the prevalence of perceive dinappropriateness of care among ICU clinicians and to identify patient-related situations, personal characteristics, and work-related characteristics associated with perceived inappropriateness of care
- To determine the prevalence of perceive dinappropriateness of care among ICU clinicians and to identify patient-related situations, personal characteristics, and work-related characteristics associated with perceived inappropriateness of care
- IN th Netherlands they make a decision …they might not discuss In italy they discuss and do not make a decision
- Frequencies of patient-related situations evoking the perception of inappropriate care
- WASHINGTON, D.C. -- Only 13% of employees worldwide are engaged at work, according to Gallup&apos;s new 142-country study on the State of the Global Workplace. In other words, about one in eight workers -- roughly 180 million employees in the countries studied -- are psychologically committed to their jobs and likely to be making positive contributions to their organizations. The bulk of employees worldwide -- 63% -- are &quot;not engaged,&quot; meaning they lack motivation and are less likely to invest discretionary effort in organizational goals or outcomes. And 24% are &quot;actively disengaged,&quot; indicating they are unhappy and unproductive at work and liable to spread negativity to coworkers. In rough numbers, this translates into 900 million not engaged and 340 million actively disengaged workers around the globe.
- However, increased use of advanced life sustaining treatment in patients with poor long term expectations secondary to more chronic organ dysfunctions and/or a poor quality of live has become a worrying trend over the last decade (1-5). 73% of European intensivists and 87% of Canadian intensivists declare that they frequently admit patients with unrealistic perspectives (6,7). Up to date, the only study which has analyzed the perception of disproportionate care by health care providers in relation to individual patients’ situations on the floor was conducted by our research group and was published in JAMA (8). In this European study 27% of a total of 1,651 interviewed doctors and nurses declared that they had to treat at least 1 patient who received disproportionate care on the day of the study. Further, 60% indicated that similar situations were common in their units. In addition, nowadays, natural or spontaneous death has become rare in the ICU due to technical innovations, and most patients die only when the intensivist, in consultation with all parties concerned, takes the decision to withhold or withdrawn therapy (9-13). Thus, ICU teams are increasingly confronted with difficult decisions concerning end of life. Furthermore, the decisions must be related to the different legal, ethical and cultural frameworks which prevail in different countries. This, together with more in depth individual psychological factors in doctors and nurses (14), often leads to postponed end of life decision-making (15-16). The results include unnecessary suffering by patients and their relatives (17,18), conflicts (19), burnout (20, 21) or high staff turnover among health care providers (8). In view of the high cost of ICU medicine (0.5 to 1% of the GDP) this also entails enormous financial implications for society (22, 23).
- Contrary to earlier publications the current project opts for the term disproportionate care rather than futile care, analogous to our landmark study published in JAMA (8). This approach has several advantages: - First, contrary to the term “futile care”, disproportionate care entails a potential bidirectional discrepancy between the administered care and the prognosis: this may be &quot;too much&quot; or &quot;not enough&quot;. Although the latter situation is rare in practice (8) it is necessary to consider this aspect as well, since both situations may arise with different health care providers, but with relation to one and the same patient. - Secondly, futile care presupposes a high degree of certainty regarding the final fatal prognosis, as the term implies that the patient will die, despite this care. However, this term does not take real life situations into account, viz. the difficulty to predict an individual patient’s survival. This is a common situation in the ICU, where technical innovations virtually exclude patients’ spontaneous death (9-11). - Thirdly, this term does not take account of the physician’s evolving opinion in daily practice concerning a patient’s prognosis. In other words, the physician needs some time before he can perceive the administered care as futile, depending on the patient’s evolution, among other things. In this respect, our terminology recognizes another phase prior to futile care: this is the period during which the physician or nurse starts to doubt whether the level of care which they administer is still appropriate. - Fourthly, every health care provider views a specific situation as a reflection of his emotional past, norms and values (24-28). As a result, different health care providers will have different views on the same patient situation. In practice the term futile care applies only as an absolute term when different expert health care providers agree that the &quot;too much&quot; care is administered. Thus the chance of futile care increases with increasing agreement among health care providers of perceived disproportional care. - Finally, the term futile care contains a negative and intentional connotation, as if physicians purposely administer futile care. This is, of course, not the case; possible explanations include an unconscious strategy of self-protection against confrontation with death (14), anxiety in decision making (29, 30), or the fear that one’s actions are considered as failure in the eyes of colleagues, relatives or society (30, 31). Lack of leadership is also an important factor in delaying end-of-life decisions in the ICU (8,15,16,19). Analysis of the ethical work climate in general and the quality of communication within and outside of the team will therefore important to take into account in this study.
- Currently 74 units in 61 hospitals in 12 countries have confirmed their participating to the study. Two countries, Portugal with 4 units, Italy with 2 units and probably (depending on timely IRB approval) the unit of victoria (national coordinators of Greece) in the UK will be activated shortly. This will make approximately 80 units in total. We did not receive any feedback from Poland yet. Fifty-two of the units were activated in the past few weeks and filled out their ICU characteristics (Phase I). The other centers will follow in comings days/weeks. Until now, 1524 HCP in these 52 centers already registered (or were registered by the local investigators) and 929 HCP (60.9%) filled out their HCP survey. Nine centers entered on time in Phase III (daily collection of HCP perception in all patients admitted in the unit and daily collection of patient’s severity of illness data only in those without exclusion criteria). Seven of these 9 centers had a HCP survey response rate &gt; 50% (up to 80% in some centers). This response rate is underestimated because 1) based on the total number of HCP entered in the ICU characteristics survey and not on the real number of HCP at the bedside during the study period and 2) a priori overestimation of the number of the units initially expected to participate in the study in some hospital). Two centers in Sweden were ready to enter Phase III on time however this has to be postponed because of delay in IRB approval. These centers together with all other centers will enter Phase III on 14 May or 21 May for a total duration of data collection of 28 days. Please for those centers / countries who did not enter yet in Phase III, keep in mind that an average center needs about 7 days to achieve a 50% response rate in the HCP survey (Phase II) because of multiple factors (human ones, spam filter and wrong email address). This is the main reasons why we decided together with the national and local investigators to postpone phase III in most of these centers. Please try to achieve this response rate of 50% in your respective units before entering in Phase III unless the units are highly motivated to start on time and the local investigators expect that the response rate will further increase in these centers during Phase III. For the first (nearly) two shifts of the day, we collected already 212 HCP perceptions in these 7 centers.
- However, increased use of advanced life sustaining treatment in patients with poor long term expectations secondary to more chronic organ dysfunctions and/or a poor quality of live has become a worrying trend over the last decade (1-5). 73% of European intensivists and 87% of Canadian intensivists declare that they frequently admit patients with unrealistic perspectives (6,7). Up to date, the only study which has analyzed the perception of disproportionate care by health care providers in relation to individual patients’ situations on the floor was conducted by our research group and was published in JAMA (8). In this European study 27% of a total of 1,651 interviewed doctors and nurses declared that they had to treat at least 1 patient who received disproportionate care on the day of the study. Further, 60% indicated that similar situations were common in their units. In addition, nowadays, natural or spontaneous death has become rare in the ICU due to technical innovations, and most patients die only when the intensivist, in consultation with all parties concerned, takes the decision to withhold or withdrawn therapy (9-13). Thus, ICU teams are increasingly confronted with difficult decisions concerning end of life. Furthermore, the decisions must be related to the different legal, ethical and cultural frameworks which prevail in different countries. This, together with more in depth individual psychological factors in doctors and nurses (14), often leads to postponed end of life decision-making (15-16). The results include unnecessary suffering by patients and their relatives (17,18), conflicts (19), burnout (20, 21) or high staff turnover among health care providers (8). In view of the high cost of ICU medicine (0.5 to 1% of the GDP) this also entails enormous financial implications for society (22, 23).