Using moral case deliberation as an analysis tool for exploring decision-making around admission to intensive care, in research before and during COVID-19

By Mia Svantesson, Bert Molewijk and Anne-Marie Slowther

This raises the question of what is or should be established good practice in this decision-making process, which is often complex, grounded in uncertainty, and taking place in a time pressured environment. It is important that in the heat of a pandemic we do not lose sight of the ethical basics of everyday practice.

Surprisingly, prior to COVID-19 there was limited published guidance for clinicians around ICU referral and admission decision-making, which prompted a multicentre research project funded by the UK National Institute of Health Research. The research team, of which MS and AS were members, were keen to explore the subtler and implicit ethical challenges inherent in the experience of making these decisions, and to explore novel methods of analysis that would capture this. To this end we turned to the clinical ethics support model of Moral Case Deliberation, in particular the dilemma method, which draws on a deliberative approach grounded in participants’ experience and conceptualisation of the ethical challenges. With input from BM and Guy Widdershoven we were able to adapt the model for use with research data. While the model is usually used to support healthcare professionals in their work, we found it particularly useful in analysing questions around responsibility for decision-making and the extent to which a decision can be delayed in order to reduce uncertainty. As we describe in our forthcoming paper in the JME, we think that making more use of methods from ethical analysis in clinical practice can add additional insights for analysing data from research in which the focus is on clinical experience.

Building on this hypothesis, and on our experience, MS and BM have integrated Moral Case Deliberation into an action research project on decision-making around ICU admission in a Swedish hospital. In this project, MCD is integrated into the research process and acts to support clinicians making explicit justifications for decisions, to provide data for further ethical analysis together with the clinic regarding justifiable reasons for decisions, that is a common value base.

In conclusion, supporting clinicians to make ethically justified decisions around admission to intensive care is crucial both during and outwith a pandemic. This includes support for prioritisation decisions but also support for the more complex relational ethical challenges that are experienced by clinicians.  Moral Case Deliberation can be a useful tool both for providing support in the clinical context and for exploring the ethical dimension of this complex decision-making process in the context of analysing data from empirical ethics research.

Paper title: Ethical conflicts during the process of deciding about ICU-admission – An empirically driven ethical analysis (Forthcoming)

Authors: Mia Svantesson, Frances Griffiths, Catherine White, Chris Bassford, Annemarie, Slowther

Affiliations: Örebro University, Örebro, Sweden and University of Warwick, Coventry, UK

Competing interests: None.

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