277: ETHICAL AND PROFESSIONAL ISSUES IN THE ICU DESCRIBED BY MEDICAL STUDENTS BEFORE AND AFTER COVID

Abstract

Introduction: Although ethical issues are common in the intensive care unit (ICU), the extent to which these controversies are incorporated into medical education and interpreted by students is less clear. Less still is known about whether student perceptions of ethical issues changed since the start of the COVID-19 pandemic. Methods: Two investigators performed qualitative content analysis on 345 reflections written by third-year medical students about ethical and professional issues encountered during their critical care rotations between March 2016 and September 2021. Coding of ethical principles was summative (based on the four biomedical ethical principles), and coding of ethical and professional issues was deductive (based on a modified version of a previously established taxonomy) and inductive. Descriptive and inferential (chi-square) statistics were performed to examine variation in ethical principles and issues pre- and post-Covid. Results: Out of the 345 reflections that were retrospectively reviewed, 245 were written pre-Covid and 98 post-Covid. Beneficence (64% pre vs 69% post, NS) and patient autonomy (66% pre vs. 54% post, p=.026) were the most commonly cited ethical principles in both time frames, often discussed concurrently and in tension. Analysis of ethical issues pre- and post-COVID were notable for several significant differences, including increased discussion of inadequate tools/ supplies/equipment (1% vs 18%, p=0.003) and inadequate level of resources or access to care (4% vs 18%, p=0.018), as well as increased concerns about efficiency over quality of care (6% vs 13%, p=.019) and the tension between law and ethics (6% vs 14%, p=.009) following the start of the pandemic. Discussion of patient/ surrogate refusal of treatment was reduced, from 10% to 2% (p=0.018) over the same period. Conclusions: Although the COVID-19 pandemic was associated with increased reflection by medical students about resources in the ICU, their perception of ethical issues arising in critical illness, both pre/post COVID, are often focused upon enduring challenges in share decision-making, including tensions between beneficence and autonomy. This information should be used to inform curriculum development for students on ICU rotations.