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Objectives: To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses' and physicians' rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses., Design: Prospective observational study., Setting: A total of 68 adult ICUs in 13 European countries and the United States., Subjects: ICU physicians and nurses., Interventions: None., Measurements and Main Results: Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses' involvement at end-of-life, average without nurses' involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions., Conclusions: Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies.

Objective: In immunocompromised patients with acute respiratory failure, invasive mechanical ventilation remains associated with high mortality. Choosing the adequate oxygenation strategy is of the utmost importance in that setting. High-flow nasal oxygen has recently shown survival benefits in unselected patients with acute respiratory failure. The objective was to assess outcomes of immunocompromised patients with hypoxemic acute respiratory failure treated with high-flow nasal oxygen., Design: We performed a post hoc analysis of a randomized controlled trial of noninvasive ventilation in critically ill immunocompromised patients with hypoxemic acute respiratory failure., Setting: Twenty-nine ICUs in France and Belgium., Patients: Critically ill immunocompromised patients with hypoxemic acute respiratory failure., Intervention: A propensity score-based approach was used to assess the impact of high-flow nasal oxygen compared with standard oxygen on day 28 mortality., Measurements and Main Results: Among 374 patients included in the study, 353 met inclusion criteria. Underlying disease included mostly malignancies (n = 296; 84%). Acute respiratory failure etiologies were mostly pneumonia (n = 157; 44.4%) or opportunistic infection (n = 76; 21.5%). Noninvasive ventilation was administered to 180 patients (51%). Invasive mechanical ventilation was ultimately needed in 142 patients (40.2%). Day 28 mortality was 22.6% (80 deaths). Throughout the ICU stay, 127 patients (36%) received high-flow nasal oxygen whereas 226 patients received standard oxygen. Ninety patients in each group (high-flow nasal oxygen or standard oxygen) were matched according to the propensity score, including 91 of 180 (51%) who received noninvasive ventilation. High-flow nasal oxygen was neither associated with a lower intubation rate (hazard ratio, 0.42; 95% CI, 0.11-1.61; p = 0.2) nor day 28 mortality (hazard ratio, 0.80; 95% CI, 0.45-1.42; p = 0.45)., Conclusions: In immunocompromised patients with hypoxemic acute respiratory failure, high-flow nasal oxygen when compared with standard oxygen did not reduce intubation or survival rates. However, these results could be due to low statistical power or unknown confounders associated with the subgroup analysis. A randomized trial is needed.

Objectives: To evaluate quality of life at least 12 months after discharge from the intensive care unit of adult critically ill patients, to evaluate the methodology used to assess long-term quality of life, and to give an overview of factors influencing quality of life., Data Sources: EMBASE-PubMed, MEDLINE (OVID), SCI/Web of Science, the Cochrane Library, Google Scholar, and personal files., Data Extraction: Data extraction was performed independently and cross-checked by two reviewers using a predefined data extraction form. Eligible studies were published between 1999 and 2009 and assessed quality of life ≥12 months after intensive care unit discharge by means of the Medical Outcomes Study 36-Item Short Form Health Survey, the RAND 36-Item Health Survey, EuroQol-5D, and/or the Nottingham Health Profile in adult intensive care unit patients., Data Synthesis: Fifty-three articles (10 multicenters) were included, with the majority of studies performed in Europe (68%). The Medical Outcomes Study 36-Item Short Form Health Survey was used in 55%, and the EuroQol-5D, the Nottingham Health Profile, the RAND 36-Item Health Survey, or a combination was used in 21%, 9%, 8%, or 8%, respectively. A response rate of ≥80% was attained in 26 studies (49%). Critically ill patients had a lower quality of life than an age- and gender-matched population, but quality of life tended to improve over years. The worst reductions in quality of life were seen in cases of severe acute respiratory distress syndrome, prolonged mechanical ventilation, severe trauma, and severe sepsis. Study quality criteria, defined as a baseline quality of life assessment, the absence of major exclusion criteria, a description of nonresponders, and a comparison with a reference population were met in only four studies (8%). Results concerning the influence of severity of illness, comorbidity, preadmission quality of life, age, gender, or acquired complications were conflicting., Conclusions: Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.

Objectives: To assess the outcome and to identify early prognostic indicators in a global population of patients with hematologic malignancy admitted to the intensive care unit for a life-threatening complication., Design: Retrospective observational study., Setting: Medical intensive care unit at a tertiary university hospital., Patients: A total of 124 consecutive critically ill patients with a hematologic malignancy admitted to the intensive care unit during a 3.5-yr period. MEASUREMENTS We collected variables at admission and during admission and identified predictors of in-hospital mortality by stepwise logistic regression analysis., Main Results: Mean Acute Physiology and Chronic Health Evaluation II score was 26 +/- 7.7. Sixty-one percent had a high-grade malignancy, and 27% had active disease. Thirty-five percent were leukopenic (leukocyte count, <1.0 x 10(9)/L) at admission. Respiratory failure (48%), sepsis (18.5%), and neurologic impairment (17%) were the major reasons for admission at the intensive care unit. Seventy-one percent of the patients required ventilatory support for a median duration of 6 (3-17) days, 46% received vasopressors at admission, and 26.6% needed renal replacement therapy during their intensive care unit stay. A recent bacteremia precipitating intensive care unit admission was found in 21.8% of the patients. Crude intensive care unit, in-hospital, and 6-month mortality rates were 42%, 54%, and 66%, respectively. Four variables were independently associated with outcome in a multivariate logistic regression analysis: leukopenia (odds ratio, 2.9; 95% confidence interval, 1.1-7.7), vasopressors (odds ratio, 3.74; 95% confidence interval, 1.4-9.8), and urea of >0.75 g/L (>12 mmol/L) (odds ratio, 9.4; 95% confidence interval, 4.2-26) at admission were associated with poor outcome, whereas recent bacteremia (odds ratio, 0.17; 95% confidence interval, 0.05-0.58) was associated with better prognosis. Using these variables, we arbitrarily categorized our population into three groups for survival analysis: a low-risk group (low urea with or without either leukopenia or vasopressors, n = 60), an intermediate-risk group (high urea or a combination of leukopenia and vasopressors, n = 34), and a high-risk group (high urea in combination with leukopenia or vasopressors, n = 27). Patients with a bacteremia prompting intensive care unit admission were allocated to a one-step-lower risk group. Survival probabilities at 30 days and 6 months were 75% and 55% in the first group, 35% and 21% in the second group, and 4% and 0%, respectively, in the third group ( <.001)., Conclusion: The general reluctance to admit patients with a hematologic malignancy to the intensive care unit, even with severe critical illness, is unjustified. However, we identified four early predictors of outcome that may be of value in deciding in which patients advanced or prolonged support should not be continued.