Ethics in Critical Care

  • Jessica Ballou
  • Karen J. Brasel


The treatment and subsequent recovery of most ICU patients present few ethical challenges. However, the nature of surgical critical care is such that psychologic and physiologic stress, end-of-life care, caretaker and family dynamics, and limited resources can result in an environment where conflict occurs. These difficult times are taxing on patients and providers alike. The purpose of this chapter is to discuss the existing consensus statements and precedents that are associated with the more common ethical dilemmas that may present in an ICU as well as identify the key principles and resources that may be applied to a variety of critical care scenarios to help providers make informed, practical decisions.


Ethics Advanced directives End of life Intensive care critical illness Ethics committee 


  1. 1.
    Schuster RA, Hong SY, Arnold RM, White DB. Investigating conflict in ICUs-is the clinicians' perspective enough? Crit Care Med. 2014;42:328–35.CrossRefGoogle Scholar
  2. 2.
    Azoulay E, Timsit JF, Sprung CL, et al. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med. 2009;180:853–60.CrossRefGoogle Scholar
  3. 3.
    Breen CM, Abernethy AP, Abbott KH, Tulsky JA. Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med. 2001;16:283–9.CrossRefGoogle Scholar
  4. 4.
    Hawryluck L, Sibbald R, Chidwick P. The standard of care and conflicts at the end of life in critical care: lessons from medical-legal crossroads and the role of a quasi-judicial tribunal in decision-making. J Crit Care. 2013;28:1055–61.CrossRefGoogle Scholar
  5. 5.
    Studdert DM, Mello MM, Burns JP, et al. Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Intensive Care Med. 2003;29:1489–97.CrossRefGoogle Scholar
  6. 6.
    Kon AA, Davidson JE, Morrison W, et al. Shared decision making in ICUs: an American College of Critical Care Medicine and American Thoracic Society Policy Statement. Crit Care Med. 2016;44:188–201.CrossRefGoogle Scholar
  7. 7.
    Heyland D, Cook D, Bagshaw SM, et al. The very elderly admitted to ICU: a quality finish? Crit Care Med. 2015;43:1352–60.CrossRefGoogle Scholar
  8. 8.
    Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32:638–43.CrossRefGoogle Scholar
  9. 9.
    Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309:470–7.CrossRefGoogle Scholar
  10. 10.
    Ortman J, Velkoff V, Hogan H. An aging nation: the older population in the United States. Washington, DC: U.S. Census Bureau; 2014.Google Scholar
  11. 11.
    Marik PE. The cost of inappropriate care at the end of life: implications for an aging population. Am J Hosp Palliat Care. 2015;32:703–8.CrossRefGoogle Scholar
  12. 12.
    Timmers TK, Verhofstad MH, Moons KG, Leenen LP. Long-term survival after surgical intensive care unit admission: fifty percent die within 10 years. Ann Surg. 2011;253:151–7.CrossRefGoogle Scholar
  13. 13.
    Danis M, Southerland LI, Garrett JM, et al. A prospective study of advance directives for life-sustaining care. N Engl J Med. 1991;324:882–8.CrossRefGoogle Scholar
  14. 14.
    Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362:1211–8.CrossRefGoogle Scholar
  15. 15.
    Swetz KM, Crowley ME, Hook C, Mueller PS. Report of 255 clinical ethics consultations and review of the literature. Mayo Clin Proc. 2007;82:686–91.CrossRefGoogle Scholar
  16. 16.
    Gilmer T, Schneiderman LJ, Teetzel H, et al. The costs of nonbeneficial treatment in the intensive care setting. Health Aff (Millwood). 2005;24:961–71.CrossRefGoogle Scholar
  17. 17.
    Andereck WS, McGaughey JW, Schneiderman LJ, Jonsen AR. Seeking to reduce nonbeneficial treatment in the ICU: an exploratory trial of proactive ethics intervention. Crit Care Med. 2014;42:824–30.CrossRefGoogle Scholar
  18. 18.
    WHO. Palliative care. 2015. Accessed 12 Dec 2016.
  19. 19.
    Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14:17–23.CrossRefGoogle Scholar
  20. 20.
    Mosenthal AC, Weissman DE, Curtis JR, et al. Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med. 2012;40:1199–206.CrossRefGoogle Scholar
  21. 21.
    Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306.CrossRefGoogle Scholar
  22. 22.
    Hawryluck LA, Harvey WR, Lemieux-Charles L, Singer PA. Consensus guidelines on analgesia and sedation in dying intensive care unit patients. BMC Med Ethics. 2002;3:E3.CrossRefGoogle Scholar
  23. 23.
    Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008;36:953–63.CrossRefGoogle Scholar
  24. 24.
    Schloendorff v. Society of New York Hospital. New York Court of Appeals; 1914.Google Scholar
  25. 25.
    In re Quinlan. New Jersey Supreme Court; 1976.Google Scholar
  26. 26.
    Cruzan v. Director, Missouri Department of Health. United States Supreme Court; 1990.Google Scholar
  27. 27.
    Prince v. Commonwealth of Massachusetts. Supreme Court of the U.S.; 1944. p. 158.Google Scholar
  28. 28.
    American Bar Association Commission on Law and Aging. Default surrogate consent statutes. 2014. Accessed 21 Oct 2016.
  29. 29.
    Cooper Z, Courtwright A, Karlage A, Gawande A, Block S. Pitfalls in communication that lead to nonbeneficial emergency surgery in elderly patients with serious illness: description of the problem and elements of a solution. Ann Surg. 2014;260:949–57.CrossRefGoogle Scholar
  30. 30.
    Boyd EA, Lo B, Evans LR, et al. “It’s not just what the doctor tells me:” factors that influence surrogate decision-makers’ perceptions of prognosis. Crit Care Med. 2010;38:1270–5.CrossRefGoogle Scholar
  31. 31.
    Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med. 2015;191:1318–30.CrossRefGoogle Scholar
  32. 32.
    Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med. 2007;35:605–22.CrossRefGoogle Scholar
  33. 33.
    De Stefano C, Normand D, Jabre P, et al. Family presence during resuscitation: a qualitative analysis from a national multicenter randomized clinical trial. PLoS One. 2016;11:e0156100.CrossRefGoogle Scholar
  34. 34.
    Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013;368:1008–18.CrossRefGoogle Scholar
  35. 35.
    Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000;100:32–42. quiz 3PubMedGoogle Scholar
  36. 36.
    Schneiderman LJ. Defining medical futility and improving medical care. J Bioeth Inq. 2011;8:123–31.CrossRefGoogle Scholar
  37. 37.
    Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med. 2013;173:1887–94.CrossRefGoogle Scholar
  38. 38.
    Schwarzkopf D, Rüddel H, Thomas-Rüddel DO, et al. Perceived nonbeneficial treatment of patients, burnout, and intention to leave the job among ICU nurses and junior and senior physicians. Crit Care Med. 2017;45:e265–73.CrossRefGoogle Scholar
  39. 39.
    White DB, Pope TM. The courts, futility, and the ends of medicine. JAMA. 2012;307:151–2.CrossRefGoogle Scholar
  40. 40.
    Fine RL. Medical futility and the Texas Advance Directives Act of 1999. Proc (Bayl Univ Med Cent). 2000;13:144–7.CrossRefGoogle Scholar
  41. 41.
    Breslow MJ, Badawi O. Severity scoring in the critically ill: part 1--interpretation and accuracy of outcome prediction scoring systems. Chest. 2012;141:245–52.CrossRefGoogle Scholar
  42. 42.
    Jones AE, Trzeciak S, Kline JA. The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med. 2009;37:1649–54.CrossRefGoogle Scholar
  43. 43.
    American College of Surgery. ACS NSQIP surgical risk calculator. 2017. Accessed 10 Jan 2017.
  44. 44.
    Sinuff T, Adhikari NK, Cook DJ, et al. Mortality predictions in the intensive care unit: comparing physicians with scoring systems. Crit Care Med. 2006;34:878–85.CrossRefGoogle Scholar
  45. 45.
    Kruser JM, Nabozny MJ, Steffens NM, et al. “Best case/worst case”: qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions. J Am Geriatr Soc. 2015;63:1805–11.CrossRefGoogle Scholar
  46. 46.
    McDonagh JR, Elliott TB, Engelberg RA, et al. Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med. 2004;32:1484–8.CrossRefGoogle Scholar
  47. 47.
    Sinuff T, Kahnamoui K, Cook DJ, Luce JM, Levy MM. Force VEaRiCCT. Rationing critical care beds: a systematic review. Crit Care Med. 2004;32:1588–97.CrossRefGoogle Scholar
  48. 48.
    Cardoso LT, Grion CM, Matsuo T, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Crit Care. 2011;15:R28.CrossRefGoogle Scholar
  49. 49.
    Bing-Hua YU. Delayed admission to intensive care unit for critically surgical patients is associated with increased mortality. Am J Surg. 2014;208:268–74.CrossRefGoogle Scholar
  50. 50.
    Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP, DELAY-ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477–83.CrossRefGoogle Scholar
  51. 51.
    Eachempati SR, Hydo LJ, Barie PS. The effect of an intermediate care unit on the demographics and outcomes of a surgical intensive care unit population. Arch Surg. 2004;139:315–9.CrossRefGoogle Scholar
  52. 52.
    Prin M, Wunsch H. The role of stepdown beds in hospital care. Am J Respir Crit Care Med. 2014;190:1210–6.CrossRefGoogle Scholar
  53. 53.
    Nates JL, Nunnally M, Kleinpell R, et al. ICU admission, discharge, and triage guidelines: a framework to enhance clinical operations, development of institutional policies, and further research. Crit Care Med. 2016;44:1553–602.CrossRefGoogle Scholar
  54. 54.
    Mathews KS, Long EF. A conceptual framework for improving critical care patient flow and bed use. Ann Am Thorac Soc. 2015;12:886–94.CrossRefGoogle Scholar
  55. 55.
    Blanch L, Abillama FF, Amin P, et al. Triage decisions for ICU admission: report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care. 2016;36:301–5.CrossRefGoogle Scholar
  56. 56.
    Hick JL, Einav S, Hanfling D, et al. Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146:e1S–e16S.CrossRefGoogle Scholar
  57. 57.
    Einav S, Hick JL, Hanfling D, et al. Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146:e17S–43S.CrossRefGoogle Scholar
  58. 58.
    Devereaux AV, Dichter JR, Christian MD, et al. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting, January 26–27, 2007, Chicago, IL. Chest. 2008;133:51S–66S.CrossRefGoogle Scholar
  59. 59.
    Bernacki RE, Block SD, Force ACoPHVCT. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174:1994–2003.CrossRefGoogle Scholar
  60. 60.
    Gries CJ, White DB, Truog RD, et al. An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ donation after circulatory determination of death. Am J Respir Crit Care Med. 2013;188:103–9.CrossRefGoogle Scholar
  61. 61.
    Kotloff RM, Blosser S, Fulda GJ, et al. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med. 2015;43:1291–325.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Oregon Health and Science UniversityPortlandUSA
  2. 2.Department of Surgery, Division of Trauma, Critical Care, and Acute Care SurgeryOregon Health and Science UniversityPortlandUSA

Personalised recommendations