Organizational ethics in urgent transfers of severely disabled people to intensive care units – a qualitative study

Abstract

Purpose

Urgent transfers of severely impaired patients with chronic neurological disability (PwND) from a neurological physical and rehabilitation medicine (nPRM) to an intensive care unit (ICU) or an emergency room (ER) served as the basis for this study. We hypothesized that human and structural factors interfered with but were not directly related to the acute context.

Methods

We decided to use a qualitative methodology, based on in-depth interviews with 16 ICU/ER physicians. We used mixed bottom-up and top-down methods. We interpreted our data using a thematic approach based on the key principles of grounded theory, which were modified with consideration of the literature.

Results

Three main domains emerged. The impact of the clinical setting notably implied the patient’s clinical typology between the acute event and the chronic background, but also bed availability. Key elements of the telephone negotiation were confidence and perceived usefulness of the transfer. Finally, the otherness of some categories of patients, transferred with more difficulty, involved those with cognitive impairment.

Conclusions

The existence of healthcare pathways for many years has created an organizational culture between departments of nPRM and ICUs. But urgent transfers also imply organizational ethics, as a balance should be struck between utility and equity.

IMPLICATIONS FOR REHABILITATION

• Structural and human factors interfere in urgent transfers, involving the settings within health pathways, the key elements of negotiation to get confidence and a perceived utility of transfer, and certain categories of people, especially those with cognitive impairment.

• Transfers that imply negotiation between practitioners from physical and rehabilitation medicine and intensive care unit departments, lead to a need of organizational ethics, as a balance should be struck between the principles of utility and equity.

• The development of facilitating tools such as a commitment charter is of paramount importance as it can support ethical decision-making.

Keywords:

• Decision resuscitation
• brain injury
• spinal cord injury
• utilitarianism
• egalitarianism
• triage
• COVID
• healthcare network

Acknowledgements

This work was greatly enhanced by the expertise and support of the personnel from the House for Clinical Research (Nantes’ University Hospital).

Ethics statement

The database was recorded in accordance with the legal French regulations (declaration to the National Commission for Data Protection, reference RC15_0232).

Consent form

Before the interviews took place written informed consent was obtained from all participants.

Author contributions

MLF reviewed the literature. MLF and IV designed the study. MLF collected and analysed the data. IV controlled the data analysis. MLF wrote the manuscript, which IV critically revised. All authors read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was granted for medical writing by Nantes’ University Hospital Research Directorate under the reference [RC12_0071_4/UF 7297].