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Table 3 Ethical problems in the ICU

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
Expansion of treatment indications ICU physician “There are a number of cases we wouldn’t have touched in the past. We wouldn’t even have been asked to consult on them. Or when we would’ve been asked, then it would always be like: ‘well, you’re not going to start this, but can you just help us with the decision not to go to the ICU with this’. But now..you see it shift because we’ve seen patients come out of a situation like that, who we’ve then given a period of good time afterward”.
  ICU nurse “The very serious COPD patients..those weren’t admitted about 10 years ago because they just thought - those aren’t going to make it. And now we still know that the odds of them making it are slim, and they are going to need a rehabilitation course of a year to survive. Well, what did we achieve then?”
Difference of opinion about the stopping of treatment ICU physician On the difference between physicians and nurses:
“Their contact with the patient is much more intense. They’re at the bedside daily, experience the patient daily, how they are feeling, what mood they’re in, those kinds of things. They suffer with them, they feel what the patient feels”.
  ICU nurse “As a nurse you see the patient more often, or you speak with the family more often. As a doctor you only see the patient when you come into the room and therefore, as a nurse, you have more feelings about..well..what you’re doing, whether you agree with it. And I think as a nurse you more often feel like, well, maybe we should stop this. Because a doctor is very much like – you’re there to make the patient better and, they don’t see the patient for very long. In any case, I can’t think of an example in which the doctor was like – ‘well, let’s stop this’, and the nurse didn’t agree with it”.
  ICU nurse “I remember a case of a pretty young guy, not yet fifty, who had had a motorcycle accident and had both legs amputated above the knee, as well as part of his arm. So he was lying in bed with one complete arm plus internal injuries and then you think, just let someone like that..because he’ll get lots of complications. With that case we [the ICU nurses; AO] were like ‘you shouldn’t do this’. Eventually the ICU physician pushed through. To this day, once every year that guy comes by to thank everyone, that they kept on and treated him. Then I’m like - here I am with my big mouth”.
  ICU physician On individual differences among ICU physicians:
“Among our staff, and I think that’s the case everywhere, there is a difference between people who are quicker to stop treatment and people who’d rather never stop, and the grey zone in the middle. Those people with the scythe who want to abstain everyone at every turn, they’re too fast. But the people who never want to stop because they think ‘well, you can never be sure, I won’t make that decision, I don’t dare to take on that responsibility’, well, they go on too long with people that really should have passed away ages ago. And the truth lies somewhere in the middle, but that’s why it’s good to discuss a decision like that during a multidisciplinary meeting, so that all the different perspectives can give their response, and that is how it happens.”
  ICU physician On the reluctance of some physicians to abstain a patient from treatment:
“That is driving up healthcare costs, giving the family false hope, causing the nursing staff to become demotivated because they already know it’s not going to work. But it takes guts and that’s a problem. It takes guts to decide this, it takes guts to go and talk to the family and say it out loud, it takes guts to explain to your colleagues that you’re not going to continue. Well, for me it’s not that hard, but it is a difficult part of our profession, with which some of my colleagues clearly have more trouble”.
Patient is stable after withdrawing life-sustaining treatment ICU physician “The patient was expected to die soon, but that didn’t happen. Then you have to, then you transfer a patient to the ward, who’ll only go there to die. That is..that was difficult for a while. But we do need that bed”.
ICU nurse “We had a case in which the doctor said - ‘okay, we’re going to transfer him to the general ward, and then a new admission will come in his place’. No way, we’re not going to do that. Then they’ll just have to transfer out someone else. But those are..we really fought about that one, you know”.
Patient is stable as long as ICU care is given ICU nurse “It’s specifically the group that kind of slips through all the cracks, a patient who starts to breathe on his own, those are the difficult categories. No one will be able to make a decision about that. Like, he breathes on his own, let’s wait and see. And ultimately it becomes days, weeks”.
  ICU physician “We create this type of patient because we can do so much […] It’s a good thing to have these patients now and again. It means the aggressiveness of your treatment is high. It means that you don’t deprive a great number of other patients. But this is the risk of being very aggressive, or going very far in your treatment”.