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.Electronic supplementary materialThe online version of this article (10.1007/s00134-018-5231-8) contains supplementary material, which is available to authorized users.

Remarks of the reviewers and answers of the authors: Could you please explain what a Belgian tertiary hospital is?We use the term 'tertiary' hospital as a synonym for a university hospital. This was adapted in the manuscript (in the abstract as well as in the method's section).Did the questionnaire you gave to the physicians also include questions why they decided to send the patients to the ICU or not?We agree that this would have been extremely valuable information. However, in order to have a maximum response rate, we used a very short questionnaire asking only objective data on the patient as well as on the DNR code and who participated in the decision to limit therapy.How was the decision made for a special DNR-Code? Was this decision mainly based on medical facts (prognosis underlying disease, comorbidity, functionality) or was this an overall decision with the participation of patient family, nurse and physician? Legal aspects in non-communicative patients -is there a legal representative who made the healthcare-decisions, or is that done by family members in Belgium?Legislation in Belgium demands that physicians inform and ask consent for every medical intervention/decision from the patient -or in case of incapacity from the surrogate decision-maker (this is in practice the nearest family).(this was added to the manuscript)The Order of Physicians in Belgium has added that it is also recommended to involve other members of the healthcare team (nurses!) in the DNR decision-making process.In this study, we see that 84% of competent patients were at least informed about the decision to limit therapy and that 100% of families of incompetent patients were informed. Only in 58%, nurses reported to be involved. (Table 1

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