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

BACKGROUND There 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. METHODS This 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. RESULTS The 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. CONCLUSIONS It 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.