Ethical content of expert recommendations for end-of-life decision-making in intensive care units: A systematic review

Abstract

Purpose: Intensive care unit health care professionals must be skilled in providing end-of-life care. Crucial in this kind of care is end-of-life decision-making, which is a complex process involving a variety of stakeholders and requiring adequate justification. The aim of this systematic review is to analyse papers tackling ethical issues in relation to end-of-life decision-making in intensive care units. It explores the ethical positions, arguments and principles.Methods: A literature search was conducted in bibliographic databases and grey literature sources for the time period from 1990 to 2019. The constant comparative method was used for qualitative analysis of included papers in order to identify ethical content including ethical positions, ethical arguments, and ethical principles used in decision-making process.Results: In the 15 included papers we have identified a total of 43 ethical positions. Ten positions were identified as substantive, 33 as procedural. Twelve different ethical principles emerged from the ethical arguments. The most frequently used principles are the principles of beneficence, autonomy and nonmaleficence.Conclusions: We have demonstrated that recommendations and guidelines designed specifically by intensive or critical care experts for intensive care units promote similar ethical positions, with minimal dissenting positions.

End-of-Life Decision-Making in Pediatric and Neonatal Intensive Care Units in Croatia—A Focus Group Study among Nurses and Physicians

“…Such experiences seem to occur at higher levels and have more devastating effects on healthcare staff working in NICUs. These findings are in line with the growing recognition that the focus should shift to the physical, mental and spiritual well-being of healthcare providers, in order to improve the quality of care and the patients' and parents' experience [2,4,12,13,19,[46][47][48]. However, although the majority of participants stressed the need for and importance of psychological support for both healthcare workers and family members, some of the participants were less enthusiastic about their implementation in the everyday work of an ICU.…”

“…In our research, physicians did not consider withdrawing or withholding treatment interventions as morally equivalent procedures. Considering the previous literature, this is quite an interesting finding, as, in most of the literature, withdrawing and withholding are considered to be equivalent [16,[42][43][44][45][46][47]. Participants placed a significant emphasis on the negative psychosocial consequences associated with everyday clinical work, facilitated by the complexities involved in end-of-life issues.…”

End-of-Life Decisions in Intensive Care Units in Croatia—Pre COVID-19 Perspectives and Experiences From Nurses and Physicians

“…Moreover, within the project we have already conducted a systematic review of ethical content of expert recommendations for end-of-life decision-making in ICUs. The following themes were highlighted in the majority of the reviewed documents and should therefore, with the others that will be additionally highlighted within this project, be part of future guidelines: respect for patients’ rights, wishes, and values, consideration of family and surrogate decision-makers wishes, adequate provision of information to patients and surrogate decision-makers, importance of psychosocial needs of patients and families, regular evaluation of treatment goals, importance of keeping good medical records (transparency), team decision-making based on consensus, non-interference of ICU team’s values with those of patients and families, importance of palliative care provision, and clarification of withholding and withdrawing of treatment (Spoljar, et al 2020 ).…”

When is it considered reasonable to start a risky and uncomfortable treatment in critically ill patients? A random sample online questionnaire study

“…The concept of inappropriateness of treatment, often also called “futility”, arises once it is realised that therapeutic measures may be technically feasible in critical care medicine but may not benefit a patient [ 1 ]. Decisions on the appropriateness of intensive care treatment should be based on fundamental ethical principles such as respect for the autonomy and dignity of the patient [ 2 – 4 ]. Interventions should aim for the well-being of the patient with avoidance of harm as the highest priority as well as fair use of available means [ 5 ].…”