By Stacey Kusterbeck
Clinicians are struggling with some intensive care unit (ICU) discharges that they believe potentially are unethical. One common example is a patient being rushed out of the ICU before the patient is adequately prepared for the next lower level of care. “This is often due to the need to admit other more critically ill patients,” says Connie M. Ulrich, PhD, MSN, RN, FAAN, professor of nursing and professor of medical ethics and health policy at Penn Nursing in Philadelphia. Ulrich and colleagues saw a need to better understand what criteria, if any, support or guide discharges from the ICU setting. “Although ICU admission and discharge are closely associated, they serve different purposes,” explains Ulrich.
Ulrich coauthored a recent paper on ethical principles involving discharge readiness.1 Applying ethical principles to the scenario helps to mitigate issues with discharges, assert the authors. “This is particularly crucial because discharge is closely associated with resource allocation, unlike ICU admission, where we assume that resources are available to admit critically ill patients,” notes Ulrich.
Often, ICU care is focused heavily on the acute presentation of disease. “But it is also important to keep in mind that ICU discharge should not be perceived as the ultimate goal. Instead, it should be viewed as a transitional moment marking the commencement of a new care trajectory for patients,” says Ulrich. Clinicians can benefit from having a broader understanding of the continuum of care and all of the factors that contribute to improved patient outcomes post-ICU discharge.
There is no one-size-fits-all ethical principle to universally guide clinicians. “However, having a set of core ethical values to provide some guidance or structure can help clinicians with clinically challenging situations,” says Ulrich. She suggests ethicists can help in these ways:
• helping clinicians analyze complex cases by considering relevant moral principles;
• facilitating mediation and conflict resolution, working toward finding common ground among multiple stakeholders;
• helping to develop or revise hospital-level policies related to ICU discharge;
• defining a core set of ethical values prioritized by the institution;
• offering recommendations to enhance ethical decision-making processes.
Ethics consultants can ensure ethical discharges in a variety of ways. “Sometimes, clinicians want validation or an outsider’s viewpoint on the specific ethical concern in front of them,” observes Ulrich.
- You SB, Ulrich CM. Ethical considerations in evaluating discharge readiness from the intensive care unit. Nurs Ethics 2023 Nov 11:9697330231212338. doi: 10.1177/09697330231212338. [Epub ahead of print.]
