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Table 2 Ethical problems related to ICU admission

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

Problem Participant Representative quotes
Delayed/refused admission General ward nurse “Look, you see a patient deteriorate and be sad and in fear and pain, and at a certain point you can’t really do much more than what the doctor says you should do and what you know you should so at that time. Of course, initially that’s the most important thing, but at a certain point you can’t do more than execute the doctor’s orders and keep the patient as stable as possible, but the capabilities of a general ward are pretty limited, you know? And then it’s just waiting for what a doctor decides and sometimes that’s..that takes a very long time”.
  General ward physician “If we [the general ward physician and the consulting ICU physician, AO] agree that the patient in question is actually an ICU patient, then I think it should be a shared responsibility. If our own ICU doesn’t have a bed, then another bed in a different place needs to be found. And then it’s not like ‘I just don’t have a bed’.”
Need to transfer a patient to a different hospital (according to guideline) ICU physician “In the beginning, I had a lot of problems with it [the guideline on an admission request in case of full bed occupancy, AO], the way it was drawn up. It went completely against my own way of thinking. I took the risks as a starting point. Which patient can you help the most here, who will suffer most from not being admitted at that moment?”
  ICU physician “There was an unspoken agreement among ICU physicians that the patient with the lowest risk went. Always. The lowest transport risk is the one to go. The guideline interfered with that concept”.
  ICU physician “This is an intrinsic error in the guideline. I think we all feel very strongly that you should act on the basis of clinical insight and weighing of risks”.
Difference of opinion about the start of ICU treatment General ward physician “I notice that the longer I’ve worked here, I kind of got..for me it’s kind of a slippery slope, because they’re not really well-defined terms you know, what futility is. I think futility is a very subjective concept and what you consider futile can be very meaningful for me, very valuable, just, that’s the way it is for such a patient too. In the beginning I was more straightforward, and now my thinking is much more nuanced and I can more easily go along with family in those cases than a couple of years ago”.
  General ward physician “To a large extent it is our interpretation of such an existence or of that quality of life, of which we think - well, is that worth the effort? Even though at such an acute time, that could be completely different for the family or the patient. I have a couple of patients that, well, literally are unable to do anything but lie in bed all day without consciousness but the family still considers it to be very meaningful”.
  ICU physician “I think we sometimes admit people we shouldn’t admit, and I think that sometimes we can say in advance that we shouldn’t have let this patient go to the ICU, but we’re too afraid that we judge things too negatively and we do it anyway, but with the result that we treat the patient for too long”.
  ICU physician “I’ve come to an age where I’ve become careful. I’ve been wrong too many times. You can only stop once”.
Decision to admit/treat was based on inaccurate/incomplete information ICU physician “The worst, I think, is when a patient is admitted who was resuscitated in the general ward and the family comes in a short time later and says - ‘daddy wouldn’t have wanted this’. Then real lines were crossed, invasive medical acts were performed based on misinformation. Well, I think that’s a shame”.
  ICU physician “Look, when it’s very difficult to keep a patient stable, it’s simple. Then you just pull out the tube, give a little morphine: done, you know? But if the patient becomes nice and stable, well, then you have a very difficult problem of course”.