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Ethical challenges for doctors and other health care professionals have existed since the practice of medicine began. Many of the oldest challenges live on to this day, such as who has more authority to make key decisions (autonomy vs. paternalism) and what are the boundaries of life at the beginning and at the end. Two powerful driving forces are new technologies and an ever-changing culture and society. The practice of medicine in intensive care units (ICUs) has been the source of many ethical challenges. Once firmly fixed concepts, such as death or "brain death" are now coming under increasing debate. In other areas, the concept of patient autonomy has been used to request life-prolonging therapies, once thought "futile." New technologies for procreation have necessitated new ethical challenges as well. In this paper, we will use a series of cases, based on experiences from our hospital ethics committee, that occurred over the course of several years and illustrate ethical challenges which are either new to us or not new but growing in frequency due to technological or societal changes. Each one of these topics is complex and worthy of its own large review but for this overview, we will briefly discuss the key points of each dilemma., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Recent studies have shown a dramatic increase in the number of intensive care unit (ICU) beds in recent decades. As technologies have become more complex, ICUs continue to grow in size and in specialization. The driving forces behind ICU bed expansion include not only the incorporation of advanced technologies but also other factors such as the increased utilization of ICU beds for patients who previously were not offered ICU care--those who may be terminally ill and those who are not critically ill. This expansion of ICU care in the United States sets it apart from other industrialized nations with comparably fewer ICU beds in relation to other hospital beds. The consequences of this expansion are now being felt in the form of unused beds, workforce shortages, and overuse of ICUs for patients who previously were not cared for in ICUs. ICUs are also now commonly used in the care of dying patients. In coming decades it is likely that changes will need to take place to forestall exorbitant costs and labor shortages. In addition to bringing in new forms of medical staff such as hospitalists and physician assistants, recent opinion papers have suggested that a de-escalation of ICU growth and a new tiered system of ICU care will be necessary in the United States., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Nurse practitioners and physician assistants are being increasingly integrated into intensive care unit and hospital-based care teams, yet limited information is available on provider to patient ratios., Objective: To determine current provider to patient ratios for nurse practitioners and physician assistants working in intensive and acute care units and to assess factors that affect the ratios., Methods: A descriptive study design was used with a Web-based survey of members of the American Association of Nurse Practitioners, American Academy of Physician Assistants, and the Society of Critical Care Medicine., Results: Responses were received from 222 nurse practitioners and 211 physician assistants from all but 8 of the 50 United States and from Canada. Mean provider to patient ratios in intensive care were 1 to 5 (range, 1 to 3 - 1 to 8). In pediatric intensive care, the mean ratio of nurse practitioners to patients was 1 to 4 (range, 1 to 3 - 1 to 8). Factors that affected nurse practitioner and physician assistant provider to patient ratios included patients' severity of illness, number of patients in the unit, number of providers in the unit, patient diagnosis, number of physicians in the unit, time of day, and number of fellows and medical residents on service., Conclusions: Additional information on factors influencing provider to patient ratios and specific components of the roles of nurse practitioners and physician assistants will be important to ensure the best utilization of these providers to enable optimal patient care outcomes., (©2015 American Association of Critical-Care Nurses.)

Purpose of Review: Growth in critical care services has led to a dramatic increase in the need for ICU physicians. The supply of intensivists is not easily increased and there is pressure to solve this problem by increasing the number of patients per intensivist. There is a scarcity of published data addressing this issue, and until recently, there were no guidelines on appropriate ratios of intensivists to patients., Recent Findings: In 2013, the Society of Critical Care Medicine formed a task force to address this issue and published written guidelines to aid hospitals in determining their intensivist staffing. This study reviews the published data which can aid these decisions and summarize the SCCM Taskforce's recommendations., Summary: The complex nature of critical care patients and ICUs make it difficult to provide one specific maximum intensivist-to-patient ratio, but common-sense rules can be applied. These recommendations are predicated on the principles that staffing can impact patient care as well as staff well-being and workforce stability. Also, that worsening patient outcomes, teaching, and workforce issues can be markers of inappropriate staffing. Finally, if the predicted daily workload of an intensivist exceeds the time of a work shift, then adjustments need to be made.

Objectives: Increases in the number, size, and occupancy rates of ICUs have not been accompanied by a commensurate growth in the number of critical care physicians leading to a workforce shortage. Due to concern that understaffing may exist, the Society of Critical Care Medicine created a taskforce to generate guidelines on maximum intensivists/patient ratios., Data Sources: A multidisciplinary taskforce conducted a review of published literature on intensivist staffing and related topics, a survey of pulmonary/Critical Care physicians, and held an expert roundtable conference., Data Extraction: A statement was generated and revised by the taskforce members using an iterative consensus process and submitted for review to the leadership council of the Society of Critical Care Medicine. For the purposes of this statement, the taskforce limited its recommendations to ICUs that use a "closed" model where the intensivists control triage and patient care., Data Synthesis and Conclusions: The taskforce concluded that while advocating a specific maximum number of patients cared for is unrealistic, an approach that uses the following principles is essential: 1) proper staffing impacts patient care; 2) large caseloads should not preclude rounding in a timely fashion; 3) staffing decisions should factor surge capacity and nondirect patient care activities; 4) institutions should regularly reassess their staffing; 5) high staff turnover or decreases in quality-of-care indicators in an ICU may be markers of overload; 6) telemedicine, advanced practice professionals, or nonintensivist medical staff may be useful to alleviate overburdening the intensivist, but should be evaluated using rigorous methods; 7) in teaching institutions, feedback from faculty and trainees should be sought to understand the implications of potential understaffing on medical education; and 8) in academic medical ICUs, there is evidence that intensivist/patient ratios less favorable than 1:14 negatively impact education, staff well-being, and patient care.

Background: Increases in the size and number of American intensive care units have not been accompanied by a comparable increase in the critical care physician workforce, raising concerns that intensivists are becoming overburdened by workload. This is especially concerning in academic intensive care units where attending physicians must couple teaching duties with patient care., Methods: We performed an in-person and electronic survey of the membership of the Association of Pulmonary and Critical Care Medicine Program Directors, soliciting information about patient workload, other hospital and medical education duties, and perceptions of the workplace and teaching environment of their intensive care units., Results: Eighty-four out of a total 121 possible responses were received from program directors or their delegates, resulting in a response rate of 69%. The average daily (SD) census (as perceived by the respondents) was 18.8 ± 8.9 patients, and average (SD) maximum service size recalled was 24.1 ± 9.9 patients. Twenty-seven percent reported no policy setting an upper limit for the daily census. Twenty-eight percent of respondents felt the average census was "too many" and 71% felt the maximum size was "too many." The median (interquartile range) patient-to-attending physician ratio was 13 (10-16). When categorized according to this median, respondents from intensive care units with high patient/physician ratios (n = 31) perceived significantly more time constraints, more stress, and difficulties with teaching trainees than respondents with low patient/physician ratios (n = 40). The total number of non-nursing healthcare workers per patient was similar in both groups, suggesting that having more nonattending physician staff does not alleviate perceptions of overwork and stress in the attending physician., Conclusions: Academic intensive care unit physicians that direct fellowship programs frequently perceived being overburdened in the intensive care unit. Understaffing intensive care units with attending physicians may have a negative impact on teaching, patient care, and workforce stability.

The objective of this prospective cohort study was to see the effect of the implementation of a Sepsis Intervention Program on the standard processes of patient care using a collaborative approach between the Emergency Department (ED) and Medical Intensive Care Unit (MICU). This was performed in a large urban tertiary-care hospital, with no previous experience utilizing a specific intervention program as routine care for septic shock and which has services and resources commonly available in most hospitals. The study included 106 patients who presented to the ED with severe sepsis or septic shock. Eighty-seven of those patients met the inclusion criteria for complete data analysis. The ED and MICU staff underwent a 3-month training period followed by implementation of a protocol for sepsis intervention program over 6 months. In the first 6 months of the program's implementation, 106 patients were admitted to the ED with severe sepsis and septic shock. During this time, the ED attempted to initiate the sepsis intervention protocol in 76% of the 87 septic patients who met the inclusion criteria. This was assessed by documentation of a central venous catheter insertion for continuous SvO(2) monitoring in a patient with sepsis or septic shock. However, only 48% of the eligible patients completed the early goal-directed therapy (EGDT) protocol. Our data showed that the in-hospital mortality rate was 30.5% for the 87 septic shock patients with a mean APACHE II score of 29. This was very similar to a landmark study of EGDT (30.5% mortality with mean APACHE II of 21.5). Data collected on processes of care showed improvements in time to fluid administration, central venous access insertion, antibiotic administration, vasopressor administration, and time to MICU transfer from ED arrival in our patients enrolled in the protocol versus those who were not. Further review of our performance data showed that processes of care improved steadily the longer the protocol was in effect, although this was not statistically significant. There was no improvement in secondary outcomes, including total length of hospital stay, MICU days, and mortality. Implementation of a sepsis intervention program as a standard of care in a typical hospital protocol leads to improvements in processes of care. However, despite a collaborative approach, the sepsis intervention program was underutilized with only 48% of the patients completing the sepsis intervention protocol.

Purpose of Review: The present study describes the use of serial severity scores to predict death in ICU patients and compares the results with previously published literature on this topic., Recent Findings: Predicting mortality in critically ill patients has tremendous significance and methods to do so accurately have been studied for decades. The ability to accurately predict death impacts medical therapies, triaging, end-of-life care, and many other aspects of ICU care. There are many methods in existence to help physicians predict mortality, but most are not very accurate on an individual basis. The main tools available are severity scores, published outcomes data, and personal experience and all of them have significant limitations. One strategy that has been shown to be effective in accurately predicting death is to use serial severity scoring during the patient's ICU admission. Recently, a retrospective study done on a large cohort of ICU patients at a single institution showed very high specificity in predicting death by using serial acute physiology, age, and chronic health evaluation (APACHE III) scores on days 1 and 3. The authors of this article sought to validate this study in a different institution using a slightly different model that was easier to use and might increase sensitivity. The results of this small study are presented with a review of the literature on the use of serial scores to predict death in ICU patients., Summary: Over the years multiple studies have shown that systems using serial severity scores can predict death in ICU patients with very high but not perfect accuracy. The clinical use of these systems remains low however and ultimately their main utility may be in research.

Objective: To examine cost constraints, resource limitations, and rationing within U.S. intensive care units (ICUs) as perceived by ICU clinicians and the roles of ICU physician and nurse directors in resource allocation decisions., Design: A national survey of hospitals with ICUs., Setting: The study included 447 U.S. hospitals with ICUs., Subjects: ICU nurse and physician directors., Interventions: None., Measurements and Main Results: We randomly selected 447 U.S. hospitals stratified for location and ICU size and contacted them for this survey. The institutional response rate was 63%. When asked to characterize their involvement in budgetary decisions, 55% of nurse directors vs. 3% (p < .001) of physician directors answered "heavy" involvement. Additionally, 91% of nurse vs. 38% of physician directors were given feedback on expenditures (p < .001). Responses to questions about specific situations or practices that may be associated with rationing showed that a substantial minority respondents perceived these practices "sometimes" (occurring 25% to 74% of the time) but the majority perceived it "rarely" (occurring <25% of the time) or not at all. Few perceived rationing as occurring "frequently" (occurring >75% of the time) because of costs or availability. When asked if any rationing occurs in their ICUs (using a prestated definition), only 11% of physician and 6% of nurse directors responded yes. Only 6% of nurses and 5% of physicians said that cost constraints have a significant effect on care. In contrast, when asked how often patients receive "too much" care, 46% of respondents said "sometimes or frequently.", Conclusions: Nurse managers have a larger role in managing ICU costs than physicians. Furthermore, both groups perceive that rationing and other cost-related practices sometimes occur in their ICU, but they more commonly perceived excessive care in ICUs. These data may be helpful for policy makers and administrators and may serve as a benchmark for future studies in critical care or other realms of health care.

As healthcare expenditures have continued to grow in the United States and elsewhere, the demand for cost-cutting measures has increased. This has led many to wonder if we are, in fact, rationing health care. Critical care is characterized by very high expenditures on a relatively few number of patients, many of whom do not survive, and it is therefore a likely place where rationing could occur. Although much has been written about the concept of rationing, there are few data about the practice, with the exception of studies that examined triaging in the intensive care unit. Research in this area is greatly hampered by the fact that identifying rationing can be very subjective given the relatively inconsistent methods by which critical care is actually practiced and the lack of a clear definition of rationing. This article reviews the concept of healthcare rationing by exploring the many different definitions and methods by which it could occur and the ethical principles underlying these methods. In addition, we review the pertinent literature on resource allocation and rationing in intensive care units.

A computerized clinical information system (CIS) is potentially a very important information tool for research and improving health care processes as well as for optimizing data management and thereby minimizing health care costs. The newest CISs automatically collect patient data from various sources, including monitors, the laboratory, radiology, and patient notes, and make the data highly organized and readily accessible. In the future CISs may be able to conduct signal analysis, assist in care decisions, provide advanced graphical data presentation, and generate warnings to clinicians. Most CIS systems include large databases, and the advent of relational databases has improved data retrieval and manipulation and thus made the data a powerful tool in outcomes research. On the whole CISs collect more frequent and more accurate data than do clinicians using paper-based data collection systems, but research continues on how accurate CIS data is, how to improve that accuracy, and how much data checking and correction is needed. At my institution we have used CIS data to study changes in patients' code status and to evaluate a protocol for arterial blood gas (ABG) testing. The primary challenges to optimizing a CIS are ensuring accurate data entry, learning to query the data so as to avoid misleading conclusions, and to administer and maintain the hardware and software so as to minimize the chance of data loss and system down time. CISs are in a relatively early stage of their development, and engineering improvements will eventually make CIS data highly accurate and easily accessible and queryable so that CISs become even more valuable for research.

Purpose: To compare the quality of data recorded by a commercially available clinical information system (CIS) to other commonly used methods for obtaining large amounts of patient data., Materials and Methods: Five sets of clinical patient data were chosen as a cross-section of all the data collected by a CIS in our intensive care unit (ICU): 1) Length of stay in the ICU, 2) Vital signs, 3) Days of mechanical ventilation, 4) medications, and 5) diagnoses. Data generated by our ICU CIS was compared with other parallel data sets commonly used to obtain the same data for clinical research., Results: When compared with our CIS, the hospital database recorded a length of stay at least 1 day longer than the actual length of stay 53% of the time. A search of 139,387 sets of vital signs showed less than 0.1% rate of suspected artifact. When compared to direct observation, our CIS correctly recorded days of mechanical ventilation in 23 of 26 patients (88%). Two other data sets, medical diagnoses and medications given showed significant differences with other commonly used databases of the same information collected outside the ICU (billing codes and pharmacy records respectively, Conclusions: Compared to other commonly used data sources for clinical research, a commercially available CIS is an acceptable source of ICU patient data.