Svantesson, Mia, Griffiths, Frances, White, Catherine, Bassford, Christopher and Slowther, Anne-Marie (2021) Ethical conflicts during the process of deciding about ICU admission : an empirically driven ethical analysis. Journal of Medical Ethics, 47 (12). e87. doi:10.1136/medethics-2020-106672 ISSN 0306-6800.

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Abstract

Background Besides balancing burdens and benefits of intensive care, ethical conflicts in the process of decision-making should also be recognised. This calls for an ethical analysis relevant to clinicians. The aim was to analyse ethically difficult situations in the process of deciding whether a patient is admitted to intensive care unit (ICU).

Methods Analysis using the ‘Dilemma method’ and ‘wide reflective equilibrium’, on ethnographic data of 45 patient cases and 96 stakeholder interviews in six UK hospitals.

Ethical analysis Four moral questions and associated value conflicts were identified. (1) Who should have the right to decide whether a patient needs to be reviewed? Conflicting perspectives on safety/security. (2) Does the benefit to the patient of getting the decision right justify the cost to the patient of a delay in making the decision? Preventing longer-term suffering and understanding patient’s values conflicted with preventing short-term suffering and provision of security. (3) To what extent should the intensivist gain others’ input? Professional independence versus a holistic approach to decision-making. (4) Should the intensivist have an ongoing duty of care to patients not admitted to ICU? Short-term versus longer-term duty to protect patient safety. Safety and security (experienced in a holistic sense of physical and emotional security for patients) were key values at stake in the ethical conflicts identified. The life-threatening nature of the situation meant that the principle of autonomy was overshadowed by the duty to protect patients from harm. The need to fairly balance obligations to the referred patient and to other patients was also recognised.

Conclusion Proactive decision-making including advance care planning and escalation of treatment decisions may support the inclusion of patient autonomy. However, our analysis invites binary choices, which may not sufficiently reflect reality. This calls for a complementary relational ethics analysis.

Item Type:	Journal Article
Subjects:	R Medicine > R Medicine (General) R Medicine > RA Public aspects of medicine
Divisions:	Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Critical care medicine -- Moral and ethical aspects, Intensive care units -- Admission and discharge -- Decision making, Critically ill -- Care, Terminally ill -- Care
Journal or Publication Title:	Journal of Medical Ethics
Publisher:	BMJ Group
ISSN:	0306-6800
Official Date:	29 November 2021
Dates:	Date Event 29 November 2021 Published 5 January 2021 Available 25 October 2020 Accepted 4 July 2020 Submitted
Volume:	47
Number:	12
Number of Pages:	10
Article Number:	e87
DOI:	10.1136/medethics-2020-106672
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access (Creative Commons)
Date of first compliant deposit:	8 August 2022
Date of first compliant Open Access:	15 August 2022
RIOXX Funder/Project Grant:	Project/Grant ID RIOXX Funder Name Funder ID 13/10/14 [NIHR] National Institute for Health Research http://dx.doi.org/10.13039/501100000272

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