The ethics of bedside priorities in intensive care : value choices and considerations : a qualitative study

Abstract

Background: The Lønning II white paper asks for more knowledge on clinical priorities in different areas of health care. This in particular goes for resources used in intensive care units. Thanks to improvements in medical and technological knowledge and a greater proportion of older patients with complex diseases intensive care units face serious challenges regarding bedside priorities. Which patients and what kind of treatment should be prioritised? Aim: The aim of this research has been to shed light on the values and considerations that affect the priority decisions with regard to limitation of intensive care treatment in intensive care. Further it was to illuminate if and how resource restrictions were followed by specific limitations in medical and nursing care. Method: This research is based on qualitative method through field observations and in-depth interviews with intensive care physicians and intensive care nurses in three intensive care units in Norwegian University Hospitals. Emphasis was on eliciting the underlying rationale for prioritisations in clinical intensive care with particular focus on clinicians’ value considerations when limiting intensive care treatment. Findings: Informants perceived that provision of treatment that was not found to be meaningful represented an increasing dilemma in intensive care. One possible explanation could be that the basis for decision-making was uncertain, complex and contradictory. The informants claimed that those who were responsible for making decisions on the admitting ward wished to prolong futile treatment because of feelings of guilt or responsibility for something that had gone wrong during the course of treatment. The assessments of the patient’s situation that were made by physicians from the admitting ward were often more organ-oriented, and their expectations tended to be less realistic than those of the clinicians in the ICU, who frequently had a more balanced perspective on the patient’s total condition. Aspects such as the personality and the specialisation of those involved, the culture of the unit and the degree of interdisciplinary cooperation constituted important issues in the decisionmaking processes. Significant others could cause unintentional discrimination of ICU patients. Family members who were demanding could receive more time and attention to the patient as well as for themselves. The status and position of patients and next of kin and /- or an interesting medical diagnosis appeared to govern the clinicians’ priorities with regard to patients and families – consciously as well as unconsciously. Scarcity of resources in the ICUs regularly gave rise to suboptimal professional standards of medical treatment and nursing care. The clinicians rarely referred to national priority criteria as a rationale for bedside priorities. Because prioritisations were undertaken implicitly and most likely partly without the clinician being aware of it, essential patient rights, such as justice and equality, could be at risk. Conclusion: Under-communicated value considerations jeopardise the principle of justice in intensive care. If intensive care patients are to be ensured equal treatment, strategies for interdisciplinary, transparent and appropriate decision-making processes must be developed, in which open and hidden values are rendered visible, power structures are revealed, employees are respected and the various perspectives on the treatment are awarded legitimate attention.