Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool

Abstract

The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians' behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

“…Country-specific health variables were retrieved from a prior publication [ 20 ]. In April and May 2014, clinicians in the participating ICUs completed questionnaires on personal characteristics, working conditions and the ethical climate prevailing in their units using the ethical decision-making climate questionnaire (EDMCQ) [ 14 ]. This questionnaire consists of 35 items with four- or five-point Likert scale options; 11 items are on end-of-life care practices; 11 on interdisciplinary reflection, collaboration, and communication and 13 on leadership skills of senior doctors.…”

“…An ethically-based clinical decision-making process has to rely on both individual perceptions and objective criteria, followed by interdisciplinary discussions that enrich the process for the benefit of the patient. However, expressing a perception of excessive care (PEC) to colleagues, and more specifically to senior ones, necessitates a safe climate in which clinicians are empowered to speak up and in which they feel that their opinion is valued and subsequently integrated into the decision-making process [ 14 ]. In addition to enhancing trust and cohesion in a team, such a climate may also reduce uncertainty in decision-makers by favoring intra- and interdisciplinary transfer of knowledge, experience and values [ 14 ].…”

“…However, expressing a perception of excessive care (PEC) to colleagues, and more specifically to senior ones, necessitates a safe climate in which clinicians are empowered to speak up and in which they feel that their opinion is valued and subsequently integrated into the decision-making process [ 14 ]. In addition to enhancing trust and cohesion in a team, such a climate may also reduce uncertainty in decision-makers by favoring intra- and interdisciplinary transfer of knowledge, experience and values [ 14 ]. Several studies have already shown that concordant prognostic estimates [ 15 , 16 ] or perceptions of inappropriate [ 17 ] or futile care [ 18 ] by two clinicians may be considerably more predictive about the patient’s short- and long-term outcomes than usually thought.…”

Competing and conflicting interests in the care of critically ill patients

“…A recent study describes the development and validation of the Ethical Decision-Making Climate Questionnaire (EDMCQ). [74, 75] This tool provides the opportunity to develop and evaluate interventions that improve an ICU’s ethical climate to facilitate ethical decision-making. Importantly, a clinician’s decisions, and the competing interests for those decisions, do not operate in a vacuum, but are instead embedded in a cultural milieu influenced by national policy, financial incentives, resource pressures, patient and family factors, and institutional leadership.…”

Building communities of respect in the intensive care unit

“…Some investigators have implemented systems for monitoring and responding to disrespect events [4]. Others have documented the ubiquity of disrespectful ICU cultures across the world [5,6]. We have also explored unintended consequences and tragic trade-offs in respect [7].…”