"I Just Really Don't Know How to Answer": Ethical Dilemmas in the Pediatric Intensive Care Unit

ContextPediatric Critical Care is inherently ethically complex, as clinicians must navigate high risk/high reward decision-making, uncertainty in prognosis and outcomes, and potential tensions between the priorities of different decision-makers and teams. While professional society guidelines and standards of care exist to guide clinicians towards resolution of ethical dilemmas, Pediatric Intensive Care Unit (PICU) clinicians still cite high levels of uncertainty when navigating these dilemmas.MethodsWe distributed a ten-question, multiple-choice survey that was distributed nationally to PCC physicians. Survey questions were designed to address the most common ethical themes identified in previously-conducted focus groups, including family preferences for end-of-life care, DNR/DNI orders, disclosure of information to adolescent patients, professional disagreements, quality of life, religious concerns, non-beneficial care, and cultural beliefs/practice.Results285 PICU physicians participated in our survey. For many questions, there was little or no consensus regarding the most appropriate response to the ethical dilemma. Free-text responses demonstrated thoughtful interaction with the ethical dilemmas and the support structures in place to help resolve the dilemmas, including ethics services and palliative care services; clinicians also highlighted the moral distress and uncertainty that can occur when clinicians engage with complicated ethical issues.ConclusionsThe variation in responses to common ethical dilemmas highlights the need for a team-based approach and rigorous support for primary teams engaging with complicated ethical situations.