Ethical problems in intensive care unit admission and discharge decisions: a qualitative study among physicians and nurses in the Netherlands

Abstract

BackgroundThere have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with.MethodsThis was an explorative, descriptive study using qualitative methods (individual and focus group interviews). We conducted 19 individual interviews and 4 focus group interviews with nurses and physicians working in the ICU or the general ward of 10 Dutch hospitals.ResultsThe ethical problems in the context of ICU admission and discharge can be divided into problems concerning full bed occupancy and problems related to treatment decisions.The gap between the high level of care the ICU can provide and the lower care level in the general ward sometimes leads to mutual misunderstandings. Our results indicate that when professionals of different wards feel there is a collective responsibility and effort to solve a problem, this helps to prevent or alleviate moral distress.ICU patients’ wishes are often unknown, causing healthcare professionals to err on the side of more treatment. Additionally, the highly technological nature of intensive care appears to encourage over-treatment.ConclusionsIt is important for ICUs and general wards to communicate and cooperate well, since there is a mutual dependency for optimal patient flow between the different departments. Interventions that improve the understanding and cooperation between these wards may help mitigate ethical problems.The nature of the ICU environment makes it important for healthcare professionals to be aware of the risk of over-treatment, reflect on why they do what they do, and be mindful of a possible negative impact of over-treatment on their patients. Early discussion of a patient’s wishes with regard to treatment options is important in preventing over-treatment.

Medical Residents’ Attitude toward Professionalism and Assessment of Their Professional Behaviors: A Cross-Sectional Survey

“…In high-pressure intensive care services and beds, deciding whether to discharge a patient who is not quite ready for the general ward to create space for another severely ill patient could be an ethical challenge for a resident. 14 In this study, there was a significant difference between the attitudes of residents in surgical fields and other residents in terms of the necessity of professionalism and ethics education. Surgery "skills-based" residents expressed a lower need for training of ethics than other specialties.…”

How Should Clinicians Respond to Medical Requests from Clinician Family Members of Patients?

“…Commentary Dr. Rose finds herself in a tough situation, perhaps one that many clinicians find equally uncomfortable: a medically unwarranted request from a colleague. Certainly differences in opinion exist among professionals in any field, but, in health care, these differences seem to carry a heavier weight-particularly if the difference in opinion involves a potentially life-threatening diagnosis [1]. In the above case, the difference in opinion is further complicated by the fact that one clinician might be considered experienced in the diagnosis of lower back pain and the other clinician inexperienced.…”

Sociodemographic Factors Influencing the Experience of Ethical Dilemmas Among Nurses in Critical Care Unit of Kenyatta National Hospital

“…Contemporary studies done in developed countries have consistently demonstrated that nurses working in critical care units as well as other areas face ethical dilemmas concerning issues of patient management [1]. The International Council of Nurses (ICN) Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct displaying a reflection of the ethical principles governing care in the critical care units.…”

“…The complex nature of the health problems faced by patients admitted in ICU coupled with extensive use of very sophisticated technology requires at times rapid decision making. These critically ill patients are vulnerable and entirely depend on the caregiver, optimally the nurse working in the critical care unit [1].The nurses working in the critical care areas also have various socio-demographic factors which may affect how they perceive ethical dilemmas and their ethical decision making process.Despite the importance of ethical dilemmas faced by these nurses, little is known about their prevalence, causes, effects and factors affecting their resolution. The existing literature focuses primarily on the problem of nursephysician conflict, and nurse-family conflict, and emphasizes coping mechanisms for nurses rather than improving patient care [11,15].…”

“…In Kenya they form 80% of the workforce as depicted in the Kenya national workforce and training analysis data (16). Nurses are deployed in nearly all the departments in the health care institutions to include the critical care units where they face various issues and are required to make decisions pertaining to patient care.Contemporary studies done in developed countries have consistently demonstrated that nurses working in critical care units as well as other areas face ethical dilemmas concerning issues of patient management [1]. The International Council of Nurses (ICN) Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct displaying a reflection of the ethical principles governing care in the critical care units.…”