Background: Non-beneficial treatment can be defined as medical interventions that are ineffective in achieving a patient’s desired goals or subject patients to discomfort without significant clinical benefit. At times, critically-ill patients are declined Intensive Care Unit (ICU) admission due to perceived lack of benefit but continue to be medically managed on the general medical floor. Caring for these patients presents numerous systems, clinical, and interpersonal challenges, as there can often be disagreement about the best course of action among clinicians or between the care team and families. Moral distress is the conflict that arises when one “knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action”. To our knowledge, there is a paucity of literature about clinicians’ perspectives in caring for this subset of patients, and in particular, no exploration of their experiences of moral distress due to these clinical situations.
Methods: We performed a qualitative survey of 73 healthcare providers including internal medicine residents, hospitalists, nurses, and social workers as part of a larger quality improvement initiative. Survey respondents were asked about various aspects related to caring for patients who had been evaluated for ICU triage by a critical care team, but were ultimately managed on the medical floor after it was determined they would not benefit from the ICU (ICU non-benefit). Participants were asked about scenarios relevant to their care and whether they experienced moral distress.
Results: Of the 73 survey respondents, 57 (81.4%) experienced moral distress when following family wishes to continue life-sustaining interventions even though they did not believe it was the best utilization of resources. 78.6% experienced moral distress caring for these patients because patient and/or family wishes for a higher level of care (i.e. the ICU) were not honored. 74.3% experienced moral distress in initiating life-saving actions because these were thought to “prolong suffering”. 61.4% felt moral distress due to disagreement with the critical care team’s decision because they believed that the patient would benefit from ICU admission.
Conclusions: Our survey results suggest that among survey respondents there was a concern that ongoing, aggressive medical interventions could lead to suffering or prolonging the dying process. The results also indicate that there is a significant degree of emotional and moral conflict on how to proceed in these complex end-of-life situations, especially in the setting of patient or family disagreement. There appears to be considerable moral uncertainty and moral distress due to issues such as family/patient preferences for ICU care, family’s unrealistic expectations about prognosis, and inadequate or ineffective communication between medical teams and family. Hospitals can build systems to support the clinical teams and help address the moral distress experienced by clinicians in these situations. At our own institution, these results have informed the development of processes to increase availability of palliative care consultation, ethics consultation and chaplaincy services in instances when critically ill patients do not benefit from care escalation to the ICU. Additionally, regular check-ins by chief residents to housestaff caring for these patients and a regular Ethics conference series were implemented to provide forums to discuss these challenging situations.