In this survey, the need for CEC perceived by the HCPs of an ICU was investigated. The questionnaire used in the study was proposed to workers in a large general Italian ICU (this ICU has a number of beds which is higher than that of most Italian ICUs), which is part of a multi-specialist hospital of the highest clinical-scientific level [18]. More than half of the respondents defined themselves as “believers” (although the degree of their faith and their specific affiliations were not investigated in detail), but this did not result in any difference in the distribution of the answers to the specific questions related to ethics consultation (questions 6–12).
Most ICU staff members were of the opinion that the clinical ethicist should help all the involved parties in a clinical case in making a shared ethical decision but should not be a “final judge” [5] of ethical disputes in a clinical setting. A considerable number of ICU staff members identified the clinical ethicist as a valid collaborator in the field of training, updating, and drafting operating procedures, testifying to the fact that the staff feel an important need for training in this area.
In reference to the first objective of the study, the “end of life” issues, as prior studies suggested, were those most deeply felt. Regarding the intervention of the clinical ethicist in ICUs, it was deemed most useful whenever there is a specific need [19,20,21].
Some examples are as follows: the compelling theme of the choice of patients to be treated, when the disproportion between needs and resources becomes unsustainable [22]; the ethical dilemmas regarding the withdrawal of life-sustaining treatments [23] (in some cases, the prolonging of a “biology” does not mean the prolonging of a “biography”); and the donation of organs for transplant, above all after circulatory death [24,25,26,27].
These are just some of the emerging ethical issues in the ICUs the solutions for which can hardly be found within the treatment team alone, made up of specialists and super-specialists who are trained in the medical field, but not in the ethical one. This is one of the reasons why the ICU unit represents an interesting context in which to apply CEC [28, 29].
Moreover, the working method must also be defined, since some principles (such as that of sharing decisions within the team and between the team and the patient/family) are widely shared, but those regarding the methods of conducting a CEC are less shared in this particular care setting [30].
The answers to the last two questions of the questionnaire (“Before this questionnaire was submitted to you, did you ever think about the need for ethical counselling in the ICU?” and “At the end of this questionnaire, it is your opinion that the activation of a clinical ethics service for intensive care is…?”) are more informative if they are read together.
In general, the subject of “clinical ethics” was considered a priority by the HCPs of this ICU, although a small number of respondents did not consider it to be so.
Regarding the second aim of the study, the most widespread opinion was that the ethics consultant should not only interface with the team as a whole, but also with patients and families, a factor that could express the propensity to involve the entire universe that revolves around the patient in the treatment (and decision-making) process [30, 31]. This is much easier to achieve in an “ICU with a partial liberalization of visiting policies”.
Regarding the third objective of the study (differences between the various categories of respondents regarding answers given), a general homogeneity can be observed. Neither age, nor sex, nor seniority of service, nor whether they are believers represent a reason for the polarization of the responses. On the contrary, different professional figures had different perceptions: in particular, the issue of the donation of organs after circulatory death was central for nurses, as was the issue of differences in diagnostic, therapeutic, and prognostic opinions, while for the doctors, the topic of indication for admission to the ICU was more binding. A common denominator in all these differences of opinion was that all would benefit from training, which helps professionals to better understand the technical phenomena and the dialogical methods involved in the decision-making process. And in this educational process, as indicated both by respondents to this survey and in previous studies, the clinical ethicist should play an important role [7, 17, 28, 29].
Limitations of the study
This study has some limitations.
Firstly, the study was performed before the activation of the ethics service. Respondents answered questions about the usefulness of a service they had not yet experienced. We also focused only on HCPs and did not investigate the patients’ and family members’ experience of ethics services.
Secondly, the participants’ religious identity was not fully investigated, particularly regarding two aspects: whether the HCP was a “believer” or not and the degree of their religiosity. Thirdly, we did not conduct a “clarity test” before administering the questionnaire to HCPs.
Future goals
A CEC who interfaces with the ICU HCPs should act both on call and as needed. The ethicist should not be a neutral “mediator.” He/she should work to improve both the decision-making process and the outcome of the process, given the moral responsibility linked to said process and the complex clinical choices to be made [32]. These choices often involve ethical dilemmas which cannot be “categorized” in a pluralistic cultural context.
Our hope is that the clinical ethicist will be able to work in an ICU together with the healthcare team by providing specialistic advice which is in line with that offered by the other specialistic consultations carried out in the hospital setting. Through specific methods and approaches, the ethics consultant is called upon to analyze and facilitate the resolution of conflicts, taking into consideration all of the stakeholders involved. The CEC thus clarifies those ethical questions which arise so that a choice may be made, together with the HCPs, regarding the most appropriate treatment path in a pluralistic and multidisciplinary medical context [33].