Bénédicte D'Anjou

The ethically charged question of what constitutes appropriate levels of care is both inevitable and particularly complex in intensive care units (ICUs), where limited resources, uncertain prognosis, and potentially conflicting values among patients, families, and ICU professionals all cohabit. While various tools have been developed to support discussions and decision-making around levels of care, they are often developed without the individuals who will ultimately use them and they fail to address the lack of interprofessional collaboration and communication between ICU professionals, a factor known to contribute to inappropriate levels of care. Living labs and the living ethics stance, which aim both to enhance collaboration and communication, represent promising research orientations for addressing this issue. This paper reports the process and outcomes of a living ethics project, which took the form of a living lab, to address the issue of inappropriate levels of care in the ICU. Special emphasis is granted to the evaluation of outcomes by participating stakeholders. This study highlights that, although inappropriate levels of care is a deeply concerning issue for which concrete contextual solutions can be envisioned, engaging in a participatory research process can be particularly challenging for overburdened critical care professionals. This difficulty stems not only from the multifactorial and emotionally charged nature of the issue, but also from the demanding context in which ICU professionals operate.

Understanding moral problems in clinical settings is central to clinical ethics consultation practice. Although this process may seem straightforward, it is in fact complex, multifaceted, and ongoing throughout consultations. Oftentimes the moral aspects of a situation will be articulated vaguely by those involved based on feelings of uneasiness and discomfort. Thus, clinical ethicists play a key role in helping to characterize these tensions in more formal and explicit terms using references to values and principles. The clinical ethics consultation literature points to the importance of this task and to some recommended practices in this process, such as those referenced in ASBH’s Core Competencies. However, there is a sizable gap between these practice guidelines and the actual methods, skills, and creativity deployed by clinical ethicists to accomplish this task. In this paper, we report a co-creative effort to lay out practices for understanding moral problems and structure them into a repertoire of practices. We followed a co-creative process involving semi-structured interviews with 20 practicing clinical ethicists as well as an iterative process involving drafting the repertoire and revising it during meetings and in manuscript form. The final repertoire structure and content includes: (1) elements considered to discern the moral nature of the problem; (2) actions and approaches taken to discern the moral nature of the problem; (3) elements considered in preparation for addressing the problem; (4) actions and approaches taken in preparation for addressing the problem; (5) modulating factors, and challenges and limits. We hope this work helps further ground the value of co-creative work in clinical ethics while also offering practical resources to support ongoing improvement of understanding moral problems in clinical ethics.

Background Levels of care deemed as inappropriate generate moral distress among nurses and other intensive care professionals. Inappropriate levels of care and related moral distress are frequently broached as individual and psychological phenomena, reduced to how individuals feel and think about specific cases. However, this tends to obscure the complex context in which these situations occur, and on which healthcare professionals can act. There is thus a need for a more contextual and team-level lens on inappropriate levels of care. Research objective This study aims to explore and understand the issue of inappropriate levels of care in an intensive care unit (ICU) through a contextual and team-level lens. Research design Semi-structured interviews were conducted with nurses, respiratory therapists, and intensivists. Thematic analysis focused on understanding the causes and consequences of inappropriate levels of care, as well as potential avenues for improvement. This study is part of a 5-phase participatory living lab project on inappropriate levels of care conducted in the ICU of a Montreal (Quebec, Canada) hospital. This paper relates the initial phases of the project, focusing on understanding the issue, with reported events spanning from June 2022 to May 2023. Ethical considerations Ethics approval was sought and granted by the Research Ethics Board of the CIUSSS de l’Est-de-l’Île-de-Montréal. Findings/Discussion Five broad themes intrinsically related to the phenomenon of inappropriate levels of care were explored with and by participants: (1) the process of determining levels of care, (2) the distinction between appropriate and inappropriate levels of care, (3) causes of inappropriate levels of care, (4) consequences of inappropriate levels of care and (5) potential avenues for improvement. Conclusion This research provides a comprehensive understanding of inappropriate levels of care in the ICU and emphasizes the relevance of team-level explorations of complex ethical issues.

Living labs are interdisciplinary and participatory initiatives aimed at bringing research closer to practice by involving stakeholders in all stages of research. Living labs align with the principles of participatory research methods as well as recent insights about how participatory ways of generating knowledge help to change practices in concrete settings with respect to specific problems. The participatory, open, and discussion‐oriented nature of living labs could be ideally suited to accompany ethical reflection and changes ensuing from reflection. To our knowledge, living labs have not been explicitly trialed and reported in ethics literature. In this discussion paper, we report and discuss four initial issues that marked the process of setting up a living lab in ethics: (1) determining the goals and expected outcomes of an ethics living lab; (2) establishing operational procedures; (3) selecting communities and defining pilot projects; and (4) adopting a lens to tackle emerging questions and challenges. We explain these four issues and present the paths taken based on the novel and specific orientation, that is, living ethics, at the basis of this project. In alignment with living ethics and É‐LABO, we approach challenges as learning opportunities to ask not only “how” questions but also “why” questions. We hope that this discussion paper informed by our experience helps to clarify the theoretical, methodological, and practical approaches necessary to successfully adopt and employ living labs in ethics.