Case Study 1
Who should have the intensive care bed?
Barry is a 32 year old man with meningitis and is brought into the A&E department of hospital A. He is unconscious with an extremely low blood pressure and evidence of renal failure. His condition is grave and without intensive care support he is almost certain to die. With intensive care support he may make a full recovery. Until this illness he has been fit and well. The Intensive Care Unit (ICU) in hospital A is full, with some patients critically ill and some in a relatively stable condition but for who optimum care would still require the facilities of an ICU. There is evidence that moving a patient from an ICU early increases their chances of complications and may increase mortality. There is an available bed in an ICU in hospital B, which is fifty miles away. The intensive care consultant on call must decide if Barry should be moved to hospital B or if a patient already in ICU should be transferred to allow Barry to be admitted. The clinical ethics committee is asked to review the case retrospectively and advise on how such cases should be approached in the future.
Questions to consider
- Does the clinical team, or the institution, owe an equal duty of care to both patients?
- If each patient is owed the same duty of care, should the aim be to maximise the chance that both patients live, or minimise the chance that both patients die.
- In contrast to 2, should the sickest patient be given any greater priority in receiving best possible care?
- If the patient in ICU is owed a greater duty of care, is this sufficient to justify the decision not to admit the other patient, given the foreseeable probable outcome?
- Is patient autonomy relevant in this situation?
Keep in mind that it is not possible to provide the best care to both patients
Discussion of the issues
The first step in considering such a dilemma is to establish the clinical facts and clarify the concepts used. This is an important part of the process of any ethical discussion, but is particularly important in issues of resource allocation when underlying ethical principles include terms such as benefit and need that may be open to interpretation.Thus information such as what will be the benefit of a certain course of action, and to whom it will accrue, and the relative need of the individuals involved, is essential to inform the ethical debate.
One way of looking at the dilemma would be to consider the relative benefit of different courses of action. The benefit to Barry of being admitted to ICU is clear; he will die if he is not given intensive care. However, the actual benefit will depend on the likelihood of his surviving even with intensive care. If his chances of making a full recovery are 80% the potential benefit will be greater than if his chance of surviving, even with intensive care, is 10%. The effect of transferring Barry to another hospital on his likely survival would also be important. For a patient already in ICU in hospital A, there can be no benefit from moving them out of ICU and transferring them to another hospital. The assessment here would be of the possible risk of such a move and the likely effect on their long-term recovery. If the risk is small, and the risk of moving Barry is great, then a utilitarian calculation of the overall benefit may support the transfer of a stable patient in hospital A to provide a bed for Barry. However, a greater risk of transfer for patients already in ICU combined with only a small chance of benefit to Barry from admission (a high likelihood that he will not survive even with treatment) may give a different answer if the criterion for the decision is overall benefit.
Responding to need
Another way of looking at this dilemma is from the point of view of the relative need for intensive care treatment. Barry is in urgent need because without intensive care treatment he will die. One can argue that we have a moral responsibility to respond to such urgent need even if the chances of success are small and it involves a small risk of potential harm to others.
Respecting a patient’s autonomous wishes is an important ethical principle in health care. What weight should be given to the refusal of a patient, or their relatives, to agree to a transfer to another hospital to allow a very sick patient to have their bed? What about the autonomous wish of the patient in the casualty department to have appropriate care in the hospital to which they have been brought? In terms of acceding to patients’ or relatives’ wishes, the principle of autonomy is not particularly helpful in this situation.
Duty of care
Health professionals in an ICU have a duty of care to their patients and must act in their patients’ best interests. Therefore it may be very difficult for them to make a decision that is not entirely in their patient’s best interest. The question arises as to whether the intensive care team also has a duty of care to a patient who is currently physically elsewhere in the hospital but who is in need of intensive care treatment. A further question is whether the hospital management has an equal duty of care to both patients, and if so how does this fit with the clinician’s duty of care?