Article Text
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.
- applied and professional ethics
- clinical ethics
- decision-making
- moral Status
- resource allocation
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Footnotes
Twitter @ICUdecisions
Contributors AMS, FG and CB designed and coordinated the NIHR project ‘Understanding and improving the decision-making process surrounding admission to the intensive care unit’. MS was the post-doctorate in the project and gathered as well as analysed the data in the ethnographic part of the project. In this paper, MS made a preliminary ethical analysis, which then were deliberated during iterative moral case deliberations within the whole author group (AMS, FG, CW, CB). MS led writing the manuscript and AS made iterative substantial contributions through the whole manuscript, with particular contribution of ethical expertise. FG, CW and CB participated in the drafting the manuscript, where CW made substantial critical intellectual input with specific contribution from ICU patient perspective, CB of clinical intensive care expertise and FG as an overall intellectual input and language review. All authors read and approved the final manuscript.
Funding This study was funded by the Department of Health, National Institute for Health Research, Health Services and Delivery Research Programme 13/10/14.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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