Intensivists' ethical perceptions about decisions to withhold or withdraw treatment: A clinical ethics empirical investigation

Background

Intensive care professional societies have issued policy recommendations regarding decisions to withhold and/or withdraw treatment (Wh&Wd) that consistently classify them as ethically equivalent and ethically neutral. However, on the ground they are often perceived as “active” and morally problematic. Moreover, recent studies have highlighted personal “variability” in the way such decisions are made. Therefore, it seemed necessary to explore intensivists' different ethical perceptions about Wh&Wd decisions.

Methods

A qualitative retrospective and multicentered study was conducted in seven intensive care units belonging to the Paris Hospital Trust (AP-HP), which involved in-depth interviews with 44 intensivists of different ages and levels of professional experience. An inductive (“grounded theory”-inspired), multidisciplinary clinical ethics approach was used that aimed at eliciting and retrieving practitioners' ethical intuitions about different Wh&Wd decisions. Interview transcripts were analyzed using a “thematic analysis” approach.

Results

Practitioners' perceptions of Wh&Wd decisions vary along two continuous dimensions: active/passive and ethically problematic/unproblematic. Three groups have been identified: those who consider Wh&Wd decisions 1) as passive and unproblematic, 2) as active and problematic, and 3) as active and unproblematic. More interestingly, these groups can be differently characterized with respect to three other ethically relevant considerations: the role of consensus during the collegial decision-making procedure, the difference between withholding and withdrawing decisions, and the definition of one's own overarching professional goal.

Conclusion

The study results allow for recognition of intensivists' moral distress about Wh&Wd decisions and open new perspectives to deal with their deep-rooted variability, most notably by working on the rationale and format of the collegial decision-making procedure.