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Abstract

Evaluating readiness for discharge from the intensive care unit (ICU) is a critical aspect of patient care. Whereas evidence-based criteria for ICU admission have been established, practical criteria for discharge from the ICU are lacking. Often discharge guidelines simply state that a patient no longer meets ICU admission criteria. Such discharge criteria can be interpreted differently by different healthcare providers, leaving a clinical void where misunderstandings of patients’ readiness can conflict with perceptions of what readiness means for patients, families, and healthcare providers. In considering ICU discharge readiness, the use and application of ethical principles may be helpful in mitigating such conflicts and achieving desired patient outcomes. Ethical principles propose different ways of understanding what readiness might mean and how clinicians might weigh these principles in their decision-making process. This article examines the concept of discharge readiness through the lens of the most widely cited ethical principles (autonomy [respect for persons], nonmaleficence/beneficence, and justice) and provides a discussion of their application in the critical care environment. Ongoing bioethics discourse and empirical research are needed to identify factors that help determine discharge readiness within critical care environments that will ultimately promote safe and effective ICU discharges for patients and their families.

Keywords

ethical theory intensive care units patient discharge principle-based ethics

Introduction

An intensive care unit (ICU) is a highly specialized unit where critical care, including various life-saving treatments, is provided. In a fast-aging society with rapid advancements in medicine, the demand for critical care beds has been increasing exponentially.¹ However, due to the limited availability of ICU beds and other resources, patients may be rushed out of the ICU before they are adequately prepared for the next lower level of care (e.g., general floor and step-down unit).^2,3 The allocation problem of limited medical resources was keenly felt during the SARs-CoV-2 virus (COVID-19) outbreak.^4,5 During this time, the need for ventilators, ICU beds, dialysis machines, and other critical care resources was high, and allocating these scare resources without guidelines was distressing for many healthcare providers. Indeed, the COVID-19 pandemic highlighted an extreme resource allocation challenge, necessitating immediate consideration of fundamental ethical frameworks to guide the distribution of scare resources by healthcare providers and by the institutions in which they worked. Further, because of continued limited ICU resources, resource allocation remains an important factor in determining patients’ discharge readiness, even after the peak of the pandemic. This has important clinical and ethical implications because multiple values are often considered in the moral decision-making process within the ICU, given the complexity and competing priorities among key stakeholders.

Discharge readiness is an important overall health outcome indicator.⁶ As such, discharging patients from the ICU before they are ready can result in longer hospital stays, increased readmissions, higher mortality, and increased healthcare costs.^1,7 On the other hand, providers want to avoid keeping patients in the hospital beyond what is necessary, because prolonged hospitalization increases the risk of hospital complications and raises healthcare costs.^8,9 Evidence suggests that care transitions are vulnerable moments when adverse events, medical errors, increased mortality, and higher healthcare costs can occur.^10–12

Current Guidelines

In 2016, the Society of Critical Care Medicine (SCCM) established evidence-based recommendations for ICU admission, discharge, and triage (ICU ADT) to promote safe and effective healthcare for critically ill patients.^13,14 Although SCCM recommends that hospitals establish discharge criteria, the guidelines do not provide specific components for such criteria.^13,15 Current guidelines define ICU discharge criteria as when patients no longer meet the criteria for ICU admission; that is, the SCCM guidelines state that ICU patients can be discharged when their physiological condition has stabilized and active ICU care and surveillance are no longer necessary.¹³ ICU admission criteria include a combination of specific needs for life-supportive therapies, availabilities for clinical expertise and resources, and potential benefits from ICU admission.¹³ These criteria are ambiguous and often dependent on context-specific situations, leaving room for healthcare providers and institutions to determine what to prioritize and what factors to consider in discharge-related decisions. Thus, such decisions can be highly subjective and not always as transparent as they should (or could) be for everyone involved.

Although the SCCM ICU ADT guidelines recommend following the American Thoracic Society (ATS)’s official statement on fair allocation of ICU resources,¹⁶ they do not delve into the specifics of how these strategies impact the allocation process or which principles should be prioritized. Additionally, ATS’s principles and positions regarding fair allocation of ICU resources are listed in the SCCM ICU ADT guidelines, but neither document provides clear guidance for providers on how to prioritize or make decisions during this process. The ATS statements supported by SCCM ICU ADT guidelines advise considering both macro-level (policy level) and micro-level (individual level) decisions. In one section of the document, it briefly discusses the connection between fair allocation and ICU discharge readiness. It explains that in situations where ICU resources are limited or fully utilized, or when the perceived need for these resources significantly exceeds their supply, patients admitted to an ICU may not receive all the necessary resources. This, in turn, can potentially lead to suboptimal discharges. However, the ATS’s section on fair allocation does not specifically detail how this might impact ICU discharge decisions. Considering that the SCCM ICU ADT guidelines have not been updated since 2016 and the ATS guidelines for fair allocation were established in 1997, predating the COVID-19 pandemic, there is an evident need for a comprehensive update not only in the context of resource allocation but overall. It is crucial to shift more focus toward ICU discharge criteria, as this not only ensures the safe transition of ICU survivors to the next level of care, preventing ICU readmission but also plays a pivotal role in making ICU resources available for others in need.

Although guidelines have shown effectiveness in reducing ICU length of stay and improving resource utilization, only a limited number of ICUs have implemented written patient discharge guidelines, and even among those that have, their consistent implementation in practice has varied.^15,17–19 Previous studies have identified factors associated with successful ICU discharge, including discharge education for patients and families, assessing and meeting patient/family needs, efficient communication among providers-providers/providers-patients, and use of discharge guidelines created by the clinicians’ healthcare institution.^1,10,18

Ethical Frameworks

During the COVID-19 pandemic, several authors discussed the importance of ethical frameworks that specifically addressed the public health crisis and the processes and practices surrounding discharge and transfer of patients.^20,21 These frameworks primarily concentrated on managing the uncertainty and day-to-day ethical decisions that clinicians were facing in allocating scarce resources. With an emphasis on decisions for rationing ventilatory support in critical care, White and Lo examined the challenges of choosing which patients to treat first when there are few resources.²⁰ The focus is often on survival through hospital discharge, which they argued is not ethically sufficient, supporting further discussions on allocating resources from one patient to another and a multiprinciple allocation approach. Such an approach advocates the integration of multiple criteria. For example, when determining ventilator allocation in situations where not all patients can receive one, factors to be considered include patients’ in-hospital survival, longer-term survival (after hospital discharge), the role of individuals in overall public health, and the life-cycle principle.

Clinical judgment in decision-making is not void of ethical values that can inform and guide clinicians in difficult and taxing patient care situations.^22,23 These bioethical underpinnings allow clinicians to consider a variety of ethical principles and theoretical perspectives, including the well-known ethical principles defined by Beauchamp and Childress.²⁴ This article examines how clinicians and others can view discharge readiness on the basis of Beauchamp and Childress’s ethical principles and factors that are emphasized when evaluating ICU discharge readiness.²⁴ Together, the four principles discussed below (autonomy[respect for persons], nonmaleficence/beneficence, and justice) form a useful ethical perspective/framework for informing ICU discharge readiness decisions. Each principle brings to the fore different factors for consideration, and depending on which factors are prioritized in determining discharge readiness and desired outcomes, each principle may lead to a different conclusion regarding discharge. When conclusions are taken together and weighed, the ethical principles can help guide clinical decisions in difficult discharge contexts.

Through discussion of each ethical principle and the factors it brings to the fore, the authors discuss areas for improvement in current ICU discharge guidelines and provide suggestions for a comprehensive evaluation of ICU discharge readiness. These suggestions could open the door for further discussion and reevaluation of current standards within the critical care community.

Application of Bioethical Principles to Discharge Readiness

Autonomy or Respect for Persons

The principle of autonomy—or respect for persons—recognizes that individuals have the right to make autonomous decisions regarding their health and well-being and also provides safeguards for those who do not have the ability to contribute to or to make decisions about their treatments.²⁵ The medical paradigm of patient- family- and person–centered care also advocates for the involvement of patients in their care.²⁶ Because patient autonomy is a foundational and guiding ethical principle in healthcare, patients should be able to make decisions that advocate for themselves and align with their values and priorities. However, patients’ agency is often constrained by their serious illness and by the imbalanced power dynamics between patients and healthcare clinicians.²⁷ Shared decision-making is often advocated as a model of deliberation, communication, and engagement between patients and their clinicians within the clinical arena but there are some patients who prefer a passive role in this relationship.^28,29 Passivity can be influenced by the power hierarchy that often positions healthcare providers in a more influential position. For example, there are situations where patients find it challenging to question or challenge healthcare providers’ decisions, particularly when their well-being or care is dependent on those decisions.^28,30–32 Nonetheless, it is ethically ideal to provide ICU patients with the ability to communicate their preferences when they have the cognitive capacity to do so.

Understandably, patients and their surrogates may have different priorities and values for the goals of care during evaluation for ICU discharge. For example, some patients may prioritize their physical condition over their psychological/mental condition, whereas their surrogates may prioritize the opposite or consider other factors based on their prior experiences or personal values. To date, ICU discharge criteria mainly focus on physiological readiness,¹³ but patients and their surrogates may have a wide range of expectations for the patient’s physical, psychological, mental, and functional conditions upon ICU discharge.

While it is necessary to honor and incorporate the values and perspectives of patients and their surrogates regarding discharge readiness, healthcare professionals also have a responsibility to advocate for what is in their patient’s best interest. Clinicians must carefully weigh the risk of harm to patients if they are directly discharged from the ICU to their home or another setting without adequate at-home or community resources, including a reliable caregiver,^33,34 or when the patient and their family want to stay in the ICU for closely monitored care even after they do not necessarily need such care.³⁵ More research is needed to gain a better understanding of how patients, their surrogates, and healthcare clinicians perceive discharge readiness and the role of autonomy in those decisions and the tensions that may exist.

Nonmaleficence and Beneficence

The principle of nonmaleficence urges healthcare providers not to inflict any harm or injury on patients.²⁴ When considering the principle of nonmaleficence, healthcare providers must prioritize the obligation to avoid causing harm to patients. Medical treatments may have both benefits and risks; however, healthcare providers should refrain from making decisions that knowingly result in more harm than good for their patients. The discharge of a patient from the ICU earlier than warranted in order to prioritize care for a more critically ill patient could be considered as indirectly inflicting harm on the discharged patient. In this situation, the healthcare provider may not have established a therapeutic patient-provider relationship to provide care to the incoming patient. An often-cited concept is a clinician’s “duty to care”—or moral responsibility for the patient already in that clinician’s care.

The SCCM’s ICU discharge guidelines focus only on physiological status without considering other conditions (e.g., cognitive and mental conditions),¹³ which has the potential to cause harm to patients because incomplete discharge assessments can lead to adverse outcomes.^6,7 In order to prevent adverse outcomes (i.e., readmission, mortality) after ICU discharge, it is crucial to consider patients’ overall functional status, including physical, cognitive, and mental conditions, when assessing the potential harms associated with their discharge. This consideration should be independent of other factors, such as resource availability, the care needs of other patients, or the ICU patient’s wishes. Post-intensive care syndrome (PICS), a cluster of complications in physical, cognitive, and mental domains, is common and observed in up to 70% of ICU survivors.^36–38 Given the high incidence of PICS, it is essential to assess and take into account the potential development of such complications when determining ICU discharge readiness. Failure to evaluate anticipated complications after ICU discharge can result in harm to patients, with long-lasting effects. Therefore, considering only one aspect of a patient’s condition, such as physical, cognitive, or mental, when determining discharge readiness may contradict the principle of nonmaleficence, because it overlooks other aspects of the patient’s status that are not yet stabilized or that need continuous monitoring.

Decisions on who will receive ICU care are often made based on speculations such as predictions of a patient’s prognosis and of possible treatment response or lack of response. Such speculations are based on providers’ best clinical judgment, which is grounded in data and experience. Providers often allocate limited resources to patients they deem likely to have a higher chance of survival and a better prognosis following ICU care. However, there are no certainties in medicine and always risks of harm. Therefore, even the most well-considered decisions may not lead to a predicted outcome for an individual patient, and patients who are deemed to have a lower chance of survival nevertheless do have a chance of survival. Each patient is unique, with a different disease trajectory, and providers cannot know whether patients who did not receive extended ICU care may have responded in an unpredicted way or have lived longer if such care was provided. Therefore, from the perspective of nonmaleficence, clinicians may inflict harm on patients by not providing ICU care, and some ICU discharge decisions could be seen as unethical because they violate the principle of nonmaleficence—not because providers or hospitals actively or directly cause harm but because such decisions may lead to readmission and other complications over a longer time frame.³⁹

Closely related to the ethical principle of nonmaleficence is the principle of beneficence. Indeed, healthcare providers have a duty to act in the best interest of their patients.²⁴ In other words, the principle of beneficence entails promoting the health and well-being of patients and striving to do good on their behalf. Nonmaleficence focuses on intentionally avoiding activities that may harm patients, whereas beneficence seeks to balance benefits and burdens to achieve the best possible outcome for patients.⁴⁰

The principles of beneficence and nonmaleficence both aim to prevent harm to patients, one by promoting good and the other by avoiding harm, and both need to be considered in making decisions about ICU discharge. For examdple, ICU discharge criteria would typically assess the comprehensive condition of patients, encompassing physical, cognitive, mental, and social well-being, in order to prevent known and predicted adverse outcomes. However, nonmaleficence entails an absolute obligation to avoid harm under all circumstances, whereas promoting good, as per the principle of beneficence, may not be an absolute requirement in all circumstances. A provider may not have a moral responsibility for a patient with whom the provider has not yet developed a special relationship. For example, an ICU provider has no special obligation—no provider-patient relationship—with a patient waiting for ICU admission because that patient is not yet under the provider’s care. However, providers are still encouraged to promote goodness and provide assistance to others.⁴⁰ Thus, when evaluating one patient’s discharge readiness while another patient is waiting for ICU admission, competing needs may surface when making decisions about how to promote the best outcomes for both patients. The principle of nonmaleficence would focus on avoiding harm to the existing ICU patient, with whom the provider has a provider-patient relationship. However, from the perspective of beneficence in the context of limited availability of ICU resources, discharge readiness decisions would take into account the best health outcomes for patients beyond the boundaries of the ICU.

Justice

In healthcare, justice is commonly equated with distributive justice or the fair distribution of scarce resources.⁴¹ The decision to admit or discharge a patient is not problematic when resources are abundant, but it becomes challenging when resources are scarce. As noted above, ethical issues surrounding resource allocation, specifically distributive justice, became prominent during the COVID-19 pandemic. In addition, readiness for discharge is often evaluated in the context of resource allocation. ICU beds and critical care resources continue to be limited, and demands for such care have increased in light of an aging population and increased severity of illness.⁴²

The SCCM ICU ADT guidelines consider institutional resource availability, such as ICU beds and life-supportive resources, but do not provide guidance on how to evaluate and distribute these limited resources. Efforts have been made to provide guidance for allocating scare resources during the pandemic, aiming to assist healthcare clinicians and communities in managing limited resources during a global health crisis. Various strategies have been suggested to aid in developing triage protocols for resource allocation decisions, with a focus on predicting in-hospital mortality, short-term mortality (typically within 1 year), and near-term mortality (usually within 5 years), and maximizing the number of saved life-years.⁴³ For instance, acute illness scores, such as the Sequential Organ Failure Assessment (SOFA) score, have often been utilized to allocate resources by predicting patients’ mortality. However, the accuracy of SOFA in predicting mortality varies^44,45 which may cast doubt on its reliability as a basis for resource allocation.⁴⁶

Another widely employed resource allocation strategy involves considering life-years saved, thus prioritizing patients who would benefit from more “life-years saved.” Age was often used as a tiebreaker when patients had similar medical conditions and required similar resources.⁴⁷ Nevertheless, concerns have been raised about the reliability of long-term life expectancy prognostication.⁴⁸ It is important to note that these strategies were not specifically designed for ICU discharge decisions (i.e., reallocating resources from one patient to another); rather, they were intended to guide the allocation of necessary resources to patients in need of treatments and resources (i.e., determining who should receive the resources). The allocation of ICU resources plays a crucial role in a patient’s outcome, making it a critical matter that requires careful consideration. To incorporate resource availability as part of discharge criteria, the ethical principle of justice should be considered. Ensuring ethical and fair distribution of limited resources is crucial to preventing reliance solely on social determinants of health.

Making moral decisions about resource allocation in complex situations typically involves many values and competing priorities. Four fundamental values are commonly employed strategies for resource allocation: (1) maximizing benefits produced from scarce resources, (2) equal treatment of people, (3) promotion and compensation of instrumental value, and (4) giving priority to those most vulnerable or in need.⁴⁹ Along with these values, factors such as age, clinical condition, expected effectiveness of treatment, and predicted survival rate are also often considered in the resource allocation decision-making process.⁴⁹

Readiness for ICU discharge could be evaluated differently depending on the conditions of other patients and the availability of resources at healthcare institutions. Even if the condition of two ICU patients is similar, decisions about discharge may be influenced by the condition of other patients waiting for ICU admission or access to ICU resources. For instance, if a patient waiting for ICU admission has a more severe clinical condition but a higher chance of survival than a current ICU patient, the ICU patient may be discharged earlier than expected, even if that patient is still recovering from deteriorated physiological status. On the other hand, an ICU patient may continue to receive ICU care if they have a higher medical priority compared with that of a waiting patient. Additionally, there may be instances where ICU discharge is delayed due to the limited availability of resources in a lower acuity area, such as wards, step-downs, or long-term care facilities, which can result in overutilization of the ICU and avoidable use of ICU days. Therefore, evaluating ICU patients’ readiness for discharge is highly dependent on the availability of resources in the next level of care and the clinical condition of the patients with whom they are being compared. Thus, when viewing ICU discharge decisions from a justice lens, it is important to acknowledge that factors beyond the patient’s current medical condition can impact the determination of ICU discharge readiness.

John Rawls, a prominent American political philosopher, has argued that achieving distributive justice is contingent upon the establishment of a nation or institution based on fair principles.⁴¹ Rawls proposed a hypothetical negotiation scenario aimed at constructing a fair social institution.⁴¹ He argued that the individuals within society would choose fair social orders when they were behind the “veil of ignorance,” wherein they are hypothetically blinded to their assigned community, wealth, abilities, or social standings.⁴¹ These principles, formulated without bias, would be fair and respectful to all members of society. Although Rawls originally applied his concept to testing the principle of a nation, it could also be applied to an institutional context.⁵⁰ Rawls might argue that achieving distributive justice in the allocation of medical resources is fundamentally challenging due to the inherent inequalities within the US health system.⁵¹ For example, access to medical treatments is often limited to those who can afford them, and some patients may decline necessary ICU care due to the financial burden.⁵¹ Additionally, hospitals vary greatly in terms of resource availability, such as the number of beds, ventilators, and healthcare professionals, which can impact patient outcomes. Proximity to well-equipped hospitals can also affect the quality of care received as well as health outcomes.^52,53 If hospitals had more resources, decisions to discharge a patient earlier than may be warranted in order to achieve a fair allocation of limited resources could be reduced.⁵⁴ Thus, from Rawls’ perspective, achieving distributive justice solely through resource allocation is difficult due to the underlying inequality in how patient access to medical care is structured within hospital systems. In upholding the ethical principle of justice, distributive justice would be achieved by considering both patient-related characteristics and the availability of institutional resources.

Discussion

Intensive care unit (ICU) is where critical and intensive care is provided. Patients who are considered for ICU admission or who are receiving ICU care are often in a life-or-death situation. As noted above, the decision to admit or discharge a patient becomes challenging when resources are scarce. Therefore, ICU discharge decisions should consider patient outcomes as well as the allocation of limited resources. In such circumstances, criteria are needed to guide healthcare providers in making informed decisions. There is no one-size-fits-all guideline for making ICU discharge decisions, and thus there is room for variability, taking into consideration complex real-life cases. However, even if a guideline is unable to provide step-by-step detailed criteria, it should describe factors to be considered, as well as strategies or resources that can be used.

Current guidelines for assessing ICU discharge readiness may simply state that a patient no longer meets ICU admission criteria, and as such the guidelines allow room for interpretation. Healthcare providers comprehensively evaluate ICU discharge readiness based on their clinical judgment and ethical principles or values that they or their institution prioritize. ICU nurses, for example, are constantly monitoring patients under their care and assessing patients’ discharge readiness, although they may not be directly involved in those decisions. During the pandemic, ICU nurses who provided care for the most critically ill patients faced a multitude of challenges, including the significant issue of ventilator shortages and transitioning patients in and out of the ICU.⁵⁵ More discussion is needed on nurses’ involvement in these decisions and the factors they prioritize when considering discharge readiness of their patients.

In addition to a patient’s health status and conditions and therapeutic efficacy, decision factors include patient and family care preferences and bioethical perspectives.⁵⁶ Bioethical principles to consider are fair resource distribution, the provider’s obligation to not cause harm, patient advocacy, and patients’ wishes. With the shift in recent decades toward patient- and family-centered care in the healthcare paradigm, it is important to actively involve patients and their care partners in the planning, delivery, and evaluation of the healthcare process.²⁶ Therefore, when making decisions about ICU discharge, it is important to actively communicate with patients and families to understand their priorities and values in care and involve them in the decision-making process. However, in cases where the values of patients and providers conflict (i.e., autonomy vs nonmaleficence), providers need to carefully balance the different ethical principles. It is important to discuss potential post-ICU complications (e.g., PICS and ICU-acquired weakness) with patients and families to support informed discharge decisions and enable early detection and timely intervention.

When determining a patient’s ICU discharge readiness, providers should keep in mind that patients are in the care continuum. ICU discharge should not be viewed as the ultimate goal, but rather as a transitional moment that marks the beginning of a new care trajectory for patients. This perspective allows healthcare providers to have a broader understanding of the continuum of care and consider comprehensive factors that contribute to improved patient outcomes following ICU discharge.

Conclusion

Timely ICU discharge reduces preventable mortality and readmission while decreasing unnecessary healthcare costs. However, as there are currently no practical and standardized ICU discharge criteria, variability in providers’ interpretations of competing priorities may play a prominent role in determining a patient’s discharge readiness. This article has explored how discharge readiness is defined in the ICU and how evaluation of discharge readiness could look different when viewed through the lens of various bioethical principles. No single principle can—or should—drive the discharge decision, but consideration of the principles of patient autonomy [respect for persons], nonmaleficence/beneficence, and justice can help guide providers toward more comprehensive assessments. To comprehensively evaluate ICU discharge readiness, providers must take into account not only various dimensions of health (not limited to the physiological aspect) but also patient values, the professional and ethical obligations as healthcare providers, and resource availability at the hospital level. ICU discharge decisions are inherently complex, and the consideration of bioethical principles discussed in this paper can provide valuable guidance to help providers navigate these complexities and support well-informed decisions.

Footnotes

Acknowledgements

The authors would like to acknowledge and appreciate Drs. Kathryn Bowles, Pamela Cacchione, and Sara Jacoby for their invaluable guidance, feedback, and support in this work.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Sang Bin You

Connie M. Ulrich

References

Hiller

Wittmann

Bracht

, et al. Delphi study to derive expert consensus on a set of criteria to evaluate discharge readiness for adult ICU patients to be discharged to a general ward—European perspective. BMC Health Serv Res 2022; 22: 773.

Quenot

J-P

Ecarnot

Meunier-Beillard

, et al. Intensive care unit strain should not rush physicians into making inappropriate decisions, but merely reduce the time to the right decisions being made. Ann Transl Med 2016; 4: 316.

Vollam

Gustafson

Morgan

, et al. Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods. Crit Care Med 2022; 50: 1083–1092.

Sekulić

Likić

Matas

. How to allocate intensive care resources during the COVID-19 pandemic: medical triage or a priori selection? Croat Med J 2020; 61: 276–278.

Klein

Bellmann

Dejaco

, et al. Structured ICU resource management in a pandemic is associated with favorable outcome in critically ill COVID-19 patients. Wien Klin Wochenschr 2020; 132: 653–663.

Suwan

Panuthai

Lasuka

, et al. Factors influencing readiness for hospital discharge among Thai older persons with chronic obstructive pulmonary disease. Pac Rim Int J Nurs Res 2018; 22: 156–168.

van Sluisveld

Oerlemans

Westert

, et al. Barriers and facilitators to improve safety and efficiency of the ICU discharge process: a mixed methods study. BMC Health Serv Res 2017; 17: 251.

Gledhill

Hanna

Nicks

, et al. Defining discharge-readiness from subacute care from all stakeholders’ perspectives: a systematic review. Disabil Rehabil 2021; 43: 3127–3134.

Shepperd

McClaran

Phillips

, et al. Discharge planning from hospital to home. Cochrane Database Syst Rev. Epub ahead of print 2010. DOI: 10.1002/14651858.CD000313.pub3.

10.

Stelfox

Lane

Boyd

, et al. A scoping review of patient discharge from intensive care. Chest 2015; 147: 317–327.

11.

Horwitz

Moin

Krumholz

, et al. Consequences of inadequate sign-out for patient care. Arch Intern Med 2008; 168: 1755.

12.

Kramer

Higgins

Zimmerman

. The association between ICU readmission rate and patient outcomes. Crit Care Med 2013; 41: 24–33.

13.

Nates

Nunnally

Kleinpell

, et al. ICU admission, discharge, and triage guidelines: a framework to enhance clinical operations, development of institutional policies, and further research. Crit Care Med 2016; 44: 1553–1602.

14.

Task Force of the American College of Critical Care Medicine . Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med 1999; 27: 633–638.

15.

Pronovost

Jenckes

Dorman

, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA 1999; 281: 1310–1317.

16.

Lanken

Terry

Adler

, et al. Fair allocation of intensive care unit resources. Am J Respir Crit Care Med 1997; 156: 1282–1301.

17.

Holcomb

Wheeler

Ely

. New ways to reduce unnecessary variation and improve outcomes in the intensive care unit: Curr Opin Crit Care 2001; 7: 304–311.

18.

Plotnikoff

Krewulak

Hernández

, et al. Patient discharge from intensive care: an updated scoping review to identify tools and practices to inform high-quality care. Crit Care 2021; 25: 438.

19.

Lin

Chaboyer

Wallis

. A literature review of organisational, individual and teamwork factors contributing to the ICU discharge process. Aust Crit Care 2009; 22: 29–43.

20.

White

. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA 2020; 323: 1773.

21.

Berlinger

Wynia

Miliken

, et al. Responding to covid-19 as a regional public health challenge: preliminary guidelines for regional collaboration involving hospitals. The Hastings Center, https://www.thehastingscenter.org/covid19-regional-ethics-guidelines/ (accessed 28 September 2023).

22.

Lechasseur

Caux

Dollé

, et al. Ethical competence: an integrative review. Nurs Ethics 2018; 25: 694–706.

23.

Kunyk

Austin

. Nursing under the influence: a relational ethics perspective. Nurs Ethics 2012; 19: 380–389.

24.

Beauchamp

Childress

. Principles of biomedical ethics. 8th ed. New York: Oxford University Press, 2019.

25.

Cohen-Almagor

. On the philosophical foundations of medical ethics: Aristotle, Kant, JS Mill and Rawls. Ethics Med Public Health 2017; 3: 436–444.

26.

NEJM . What Is Patient-Centered Care? NEJM Catal, https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559 (2017, accessed 26 November 2022).

27.

Jaiswal

. Whose Responsibility Is It to Dismantle Medical Mistrust? Future Directions for Researchers and Health Care Providers. Behav Med 2019; 45: 188–196.

28.

Chewning

Bylund

Shah

, et al. Patient preferences for shared decisions: A systematic review. Patient Educ Counsel 2012; 86: 9–18.

29.

Eliacin

Salyers

Kukla

, et al. Factors influencing patients’ preferences and perceived involvement in shared decision-making in mental health care. J Ment Health 2015; 24: 24–28.

30.

Reed

. Intermodernism: A Philosophical Perspective for Development of Scientific Nursing Theory. Adv Nurs Sci 2019; 42: 17–27.

31.

Charles

Gafni

Whelan

. Decision-making in the physician–patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999; 49: 651–661.

32.

Nimmon

Stenfors-Hayes

. The “Handling” of power in the physician-patient encounter: perceptions from experienced physicians. BMC Med Educ 2016; 16: 114.

33.

Lau

Donnelly

Parvez

, et al. Safety outcomes of direct discharge home from ICUs: an updated systematic review and meta-analysis (direct from ICU sent home study). Crit Care Med 2023; 51: 127–135.

34.

Stelfox

Soo

Niven

, et al. Assessment of the safety of discharging select patients directly home from the intensive care unit: a multicenter population-based cohort study. JAMA Intern Med 2018; 178: 1390–1399.

35.

Kirschner

. Drama and Trauma: Unpacking moral distress in the context of discharge planning. Narrat Inq Bioeth 2020; 10: 223–230.

36.

Davidson

Jones

Bienvenu

. Family response to critical illness: postintensive care syndrome–family. Crit Care Med 2012; 40: 618–624.

37.

Needham

Davidson

Cohen

, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholdersʼ conference. Crit Care Med 2012; 40: 502–509.

38.

Society of Critical Care Medicine . SCCM | critical care statistics. https://sccm.org/Communications/Critical-Care-Statistics (accessed 25 September 2022).

39.

Jeong

B-H

Lee

D-S

, et al. Readmission and hospital mortality after ICU discharge of critically ill cancer patients. PLoS One 2019; 14: e0211240.

40.

Thompson

. Principles of ethics: in managing a critical care unit. Crit Care Med 2007; 35: S2–S10.

41.

Rawls

. Justice as fairness: a restatement. Harvard University Press, 1971.

42.

Zimmerman

Kramer

Knaus

. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Crit Care 2013; 17: R81.

43.

Lemmon

Truog

Ubel

. Allocating resources across the life span during COVID-19—integrating neonates and children into crisis standards of care protocols. JAMA Pediatr 2021; 175: 347.

44.

Khan

Hulme

Sherwood

. An assessment of the validity of SOFA score based triage in H1N1 critically ill patients during an influenza pandemic. Anaesthesia 2009; 64: 1283–1288.

45.

Zhou

, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet Lond Engl 2020; 395: 1054–1062.

46.

Walsh

Chakravarti

. Operationalizing crisis standards of care: the potential hazards of relying on SOFA scores for resource allocation | COVID in focus - American college of chest physicians, https://www.chestnet.org/topic-collections/covid-19/covid-in-focus/operationalizing-crisis-standards-of-care (2021, accessed 28 September 2023).

47.

May

Aulisio

. Age, “Life-Cycles,” and the Allocation of Scarce Medical Resources. Chest 2020; 158: 1837–1838.

48.

Farrell

Hung

Unroe

, et al. Exploring the Intersection of Structural Racism and Ageism in Healthcare. J Am Geriatr Soc 2022; jgs.18105.

49.

Emanuel

Persad

Upshur

, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med 2020; 382: 2049–2055.

50.

McMillan

Hope

. Justice-based obligations in intensive care. Lancet 2010; 375: 1156–1157.

51.

Dickman

Himmelstein

Woolhandler

. Inequality and the health-care system in the USA. Lancet 2017; 389: 1431–1441.

52.

Chou

Deily

. Travel Distance and Health Outcomes for Scheduled Surgery. Med Care 2014; 52: 250–257.

53.

Kelly

Hulme

Farragher

, et al. Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review. BMJ Open 2016; 6: e013059.

54.

Levinson

Cantor

Williams

, et al. The association of strained ICU capacity with hospital patient racial and ethnic composition and federal relief during the COVID ‐19 pandemic. Health Serv Res 2022; 57: 279–290.

55.

Guttormson

Calkins

McAndrew

, et al. Critical care nurse Burnout, Moral distress, and mental health during the COVID-19 pandemic: a United States survey. Heart Lung 2022; 55: 127–133.

56.

Sinuff

Kahnamoui

Cook

, et al. Rationing critical care beds: a systematic review. Crit Care Med 2004; 32: 1588–1597.

Ethical considerations in evaluating discharge readiness from the intensive care unit