Antibiotic Susceptibility Patterns of Bacterial Isolates from Routine Clinical Specimens: A Contemporary Analysis to Guide Empirical Antimicrobial Therapy to Address Antimicrobial Resistance

Dear Editor, We thank Dr. Quartin et al. for their interest and comments on our recently published article on the accuracy of plasma neutrophil gelatinase-associated lipocalin (pNGAL) in the early diagnosis of contrast-induced acute kidney injury (CI-AKI) in the intensive care unit (ICU) setting [1]. Questions have been raised about the definition of CI-AKI used and on the reality of CI-AKI in critically ill patients [2]. There is no consensus definition of CI-AKI, and we used the Acute Kidney Injury Network (AKIN) criteria because, in a previous study performed in a surgical ICU in our university hospital, AKIN classification was the most sensitive definition to detect CI-AKI, also being associated with two important outcomes: renal replacement therapy and mortality. This definition presents the advantage of taking into account modest increases in creatinine concentration, and it has already been demonstrated that even small creatinine variations are associated with prognosis. Moreover, we used both creatinine and urine output criteria for CI-AKI diagnosis, as recently recommended in the Kidney Disease: Improving Global Outcomes (KDIGO) AKI guideline. As mentioned in our article, CIAKI could not be exclusively related to contrast medium (CM) administration because of the complexity of ICU patients, who frequently present multiple risk factors that can influence kidney function. We have already discussed this issue and its potential consequences for the interpretation of the study results in the journal. To limit this selection bias, we excluded all patients who had unstable renal function within the 48 h before CM injection. Obviously, this does not mean that CM was the only factor implicated in subsequent AKI, but in these conditions pNGAL should have been able to detect any new AKI related exclusively to CM administration or not. In recent years, some studies have investigated the impact of CM administration on AKI development after a radiographic examination by matching ICU patients with and without CM exposure on arbitrarily chosen variables or on the propensity to have CM injection. These studies found that patients who had no CM administration had the same AKI incidence as those who received CM. So, they concluded that CM had minimal impact on kidney function variations after radiologic examination in ICU patients. Unfortunately, these studies had similar bias. Indeed, because of the complexity of critically ill patients, all factors that could influence kidney function cannot be matched, and differences in unmatched variables could unbalance groups and hide the nephrotoxicity of CM. Overall, both methods used to study CI-AKI in the ICU setting (patient selection or matching) have flaws, and actually it is very difficult to determine the real impact of CM administration in AKI occurring after CM exposure in ICU patients. Must we, however, neglect a pathology already identified outside the ICU setting on the pretext that it is difficult to characterize in critically ill patients? Common sense tells us no. Thus, new efforts are warranted to identify patients most at risk of CIAKI and to determine the best prevention strategy in the ICU setting.

Frequent pain monitoring in intensive care unit (ICU) settings has been shown to have achieved improvement in patient outcomes. Specifically, the nursing staff is required to assess the pain of the patients approximately every four hours, and make necessary pain medication adjustments. Shortage and overburdening of nursing staff is well acknowledged in many hospital settings worldwide. In this paper, we present a preliminary study on automatic recognition of facial expression of pain in ICU settings. There has been considerable work on computer based pain recognition for settings beyond the ICU, wherein, usually the entire face of the person is visible without occlusions. The ICU setting, however, brings along unique challenges for recognizing facial expression of pain – the patient’s face is often covered by a respirator mask, the face is partially occluded by accessories attached to the respirator, and the patient is occasionally in a transient state of consciousness. In this paper we investigate the use of computer vision techniques for recognizing pain from partially visible faces. To establish a proof-of-concept, we simulate the occlusions most likely to happen in an ICU setting by masking out the nose, cheeks, and mouth regions, and use only a narrow band around the eyes of the patient as an input to our method. We generate these simulated occlusions using data from the UNBC-McMaster pain expression archive −a previously used dataset for pain expression recognition based on fully visible faces. We investigate multiple feature representations by extracting features only on the basis of the eye-region and train classifiers to detect the presence of pain using leave-one-person-out cross validation. Our results suggest a potential viability of automatic pain monitoring in the ICU settings involving face occlusions.

Peripherally inserted central venous catheters (PICCs) are now commonly used for central access in the intensive care unit (ICU) setting; however, there is a paucity of data evaluating the complication rates associated with these lines. We performed a retrospective review of all PICCs placed in the inpatient setting at our institution during a 1-year period from January 2013 to December 2013. These were divided into two groups: those placed at the bedside in the ICU and those placed by interventional radiology in non-ICU patients. Data regarding infectious and thrombotic complications were collected and evaluated. During the study period, 1209 PICC line placements met inclusion criteria and were evaluated; 1038 were placed by interventional radiology in non-ICU patients, and 171 were placed at the bedside in ICU patients. The combined thrombotic and central line associated blood stream infection rate was 6.17 per cent in the non-ICU group and 10.53 per cent in the ICU group (P = 0.035). The thrombotic complication rate was 5.88 per cent in the non-ICU group and 7.60 per cent in the ICU group (P = 0.38), whereas the central line associated blood stream infection rate was 0.29 per cent in the non-ICU group and 2.92 per cent in the ICU group (P = 0.002). This study seems to suggest that PICC lines placed at the bedside in the ICU setting are associated with higher complication rates, in particular infectious complications, than those placed by interventional radiology in non-ICU patients. The routine placement of PICC lines in the ICU settings needs to be reevaluated given these findings.

Dominant models of prioritising resources in intensive care unit (ICU) settings under conditions of severe resource scarcity, such as a pandemic, are likely to replicate and potentially exacerbate existing health inequities. One proposal is to advance equity by reserving a proportion of ICU resources, such as beds, for members of specific groups. This qualitative study explored the ethical acceptability of a reserve bed system (RBS) for healthcare workers and for indigenous Māori in the Aotearoa New Zealand context. Participants included Māori and non-Māori clinicians working in ICU settings, and non-clinical staff with expertise in ICU management and policy. Although there was a consensus on the urgency of addressing health inequities in New Zealand, especially for indigenous Māori, participants identified critical ethical challenges in implementing an RBS in the ICU setting. These findings contribute to the broader literature on the ethics of reserve systems for priority-setting.

Antimicrobial stewardship programs (ASPs) using audit and feedback in the intensive care unit (ICU) setting can reduce harms related to inappropriate antibiotic use. However, inappropriate discontinuation or narrowing of antibiotic treatment could increase infection-related mortality in this population. Individual ASP studies are underpowered to detect differences in mortality. We conducted a systematic review and meta-analysis of audit and feedback in the ICU setting, using mortality as our outcome. Of 2447 citations, 11 studies met our inclusion criteria. Although a variety of study designs were used to assess reductions in antibiotic use, mortality was analyzed using an uncontrolled before-after study design in all studies. Five studies directed audit and feedback to all or most ICU patients receiving antibiotics and measured overall ICU mortality. In the meta-analysis of these studies, the pooled relative risk of ICU mortality was 1.03 (95% confidence interval, .93-1.14). A second meta-analysis of 3 smaller studies that evaluated mortality only in patients directly assessed by the ASP found a pooled relative risk of ICU mortality of 1.06 (95% confidence interval, .80 to 1.4). Three studies were not appropriate for meta-analysis, but their results were consistent with our overall findings. Our systematic review did not identify a change in mortality associated with antimicrobial stewardship using audit and feedback in the ICU setting. These results increase our confidence that audit and feedback can be safely implemented in this setting. Future studies should report standardized estimates of mortality and use more robust study designs to assess mortality, when feasible.

Management and leadership of intensive care units for the future.

Inpatient diabetes management is challenging due to acute illness, variable insulin requirements, and reliance on intermittent point-of-care glucose testing. Both hyperglycemia and hypoglycemia are associated with increased costs, length of stay, morbidity, and mortality. However, efforts to achieve tighter glycemic targets are often limited by the risk of iatrogenic hypoglycemia. Notably, hypoglycemia (glucose <3.9 mmol/L, <70 mg/dL) occurs in approximately 10% of patients in intensive care unit (ICU) settings and 3.5% of non-ICU patients and is strongly linked to mortality. Automated insulin delivery (AID) systems may improve inpatient glycemic targets while minimizing the risk of hypoglycemia. This systematic review aimed to evaluate the effects of AID systems in hospital settings. A systematic literature search was conducted on March 27, 2026, in MEDLINE, Embase, and CENTRAL, without restrictions on publication date. Randomized controlled trials (RCTs) involving inpatients managed with AID systems were included if they reported glycemic and/or clinical outcomes. Analyses were performed for ICU and non-ICU settings separately. The primary outcome was time in range (TIR) 5.6-10.0 mmol/L (100-180 mg/dL). The reporting follows the PRISMA 2020 guidelines, and the protocol was registered with PROSPERO (CRD420261308501). A total of 4858 references were screened. Five RCTs from the non-ICU setting (N = 300 participants [>80% with type 2 diabetes]) and three RCTs from the ICU setting (N = 142 [with and without preexisting diabetes]) were identified. Meta-analysis of RCTs in the non-ICU setting showed that AID increased TIR by 24.6 percentage points (95% confidence interval 20.7-28.5). A meta-analysis on ICU data could not be conducted. Across all settings, AID was associated with reduced hyperglycemia without an increase in hypoglycemia. Clinical outcomes were sparsely reported. AID systems can be safely and effectively used in non-ICU hospital settings to improve glycemic outcomes. Larger, multicenter trials are needed to confirm clinical benefits and address implementation challenges.

The acceptability of waiver of consent for participation in clinical research in intensive care unit (ICU) settings is uncertain. We sought to survey the Canadian public to assess levels of support, comfort, and acceptability for waived consent for low-risk clinical trials. We performed a prospective cross-sectional survey of the Canadian public aged 18yr or older. The survey was conducted by Ipsos between 19 and 23 November 2020. The survey content was derived from a literature review and in consultation with a patient and family partnership committee. The survey focused on attitudes and beliefs on waived consent for participation in low-risk clinical trials in ICU settings. The survey contained 35 items focused on sociodemographics, general health status, participation in medical research, and levels of support and comfort with research and with waived consent. The survey used a case study of a low-risk clinical trial intervention in ICU patients. Analysis was descriptive. We included 2,000 participants, 38% of whom reported experience with ICU and 16% with medical research. Participation in medical research was more common among those with postsecondary education, those with chronic disease, and those who were employed in health care. Most (80%) would support a model of waived consent for low-risk clinical trials, citing medical benefits (36%) and low perceived risk (34%). Most (77%) were comfortable with personally participating in a low-risk clinical trial. Most (80%) believed waived consent approaches were acceptable. Half (52%) believed the waived consent process should provide information about the research and include the option of opting out. When asked whether participants should always give full informed consent, regardless of the practicality or level of risk, 74% and 72% agreed, respectively. There is public support for models of waived consent for participation in low-risk pragmatic clinical trials in ICU settings in Canada; however, this is not universal. This information can inform and guide education, ethics, policy, and legal discussion on consent models.

To describe the benefits of smart infusion pump interoperability with an electronic medical record (EMR) system in an adult intensive care unit (ICU) setting. In order to assess the impact of smart infusion pump and EMR interoperability, we observed whether there were changes in the frequency of electronic medication administration record (eMAR) documentation of dose titrations in epinephrine and norepinephrine infusions in the ICU setting. As a secondary endpoint, we examined whether smart pump/EMR interoperability had any impact on the rate of alerts triggered by the dose-error reduction software. Pharmacist satisfaction was measured to determine the impact of smart pump/EMR interoperability on pharmacist workflow. In the preimplementation phase, there were a total of 2,503 administrations of epinephrine and norepinephrine; 13,299 rate changes were documented, for an average of 5.31 documented rate changes per administration. With smart pump interoperability, a total of 13,024 rate changes were documented in association with 1,401 administrations, for an average of 9.29 documented rate changes per administration (a 74.9% increase). A total of 1,526 dose alerts were triggered in association with 76,145 infusions in the preimplementation phase; there were 820 dose alerts associated with 48,758 autoprogammed infusions in the postimplementation phase (absolute difference, -0.32%). ICU pharmacists largely agreed (75% of survey respondents) that the technology provided incremental value in providing patient care. Interoperability between the smart pump and EMR systems proved beneficial in the administration and monitoring of continuous infusions in the ICU setting. Additionally, ICU pharmacists may be positively impacted by improved clinical data accuracy and operational efficiency.

Introduction: The Coronavirus Disease-2019 (COVID-19) pandemic has exacerbated the global challenge of antibiotic resistance, particularly among respiratory pathogens. Findings from previous research highlight the urgent need to address antibiotic resistance in respiratory isolates during the COVID19 era. Aim: To investigate the changing trends in bacterial isolates, their prevalence, and antibiotic resistance patterns in respiratory samples from ward and Intensive Care Unit (ICU) settings during the pre-COVID-19 (2019), COVID-19 (2020), and post-COVID19 (2022) periods. Materials and Methods: A cross-sectional study was conducted in the Department of Microbiology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India. The study covered a three-year period from January 2019 to December 2022, excluding the year 2021. Respiratory samples such as Endotracheal Aspirates (ETA), Bronchoalveolar Lavage (BAL), and sputum that were culture positive were included for bacterial isolation and analysis of antibiotic resistance patterns. Data were collected from both ward and ICU patients, and statistical comparisons across the three study periods were performed using the Chi-square test to calculate p-values. Results: A total of 830, 520, and 695 culture-positive respiratory isolates were analysed in 2019, 2020, and 2022, respectively. In the ICU, Acinetobacter spp. showed a significant increase from 26.49% in 2019 to 51.16% in 2020, followed by a marginal decline to 48.14% in 2022 (p-value &lt;0.001). Klebsiella spp. exhibited a gradual rise in prevalence, while Pseudomonas aeruginosa initially decreased during the COVID-19 period but rebounded post-COVID-19. Antibiotic resistance patterns revealed a significant increase in resistance to colistin, imipenem, piperacillin-tazobactam, and tigecycline, particularly among Klebsiella spp. and Acinetobacter spp. in ICU settings. Conclusion: The study highlights a concerning rise in antibiotic resistance among respiratory pathogens during the COVID19 and post-COVID-19 periods, particularly in ICU settings. These findings emphasise the need for stringent antimicrobial stewardship, strengthened infection control measures, and continuous surveillance of resistance patterns to mitigate the spread of Multidrug-Resistant (MDR) bacteria.

Acinetobacter baumannii is responsible for causing difficult-to-treat healthcare-associated infections globally, owing to its resistance to antibiotics. The intensive care unit (ICU) settings mediate spread of multidrug resistance (MDR) strains. This research aimed to evaluate non-susceptible colistin and fosfomycin A. baumannii, harboring extended-spectrum beta-lactamases (ESBLs) and carbapenemases in ICU setting. During the period of 2019-2021, this study obtained 200 A. baumanni isolates out of 1410 burns samples from an ICU setting. The antibiotic sensitivity, ESBLs and carbapenemase production were determined using clinical and laboratory standards institute (CLSI) 2020. The colistin (mcr-1 and mcr-2) and fosfomycin (fosA3) resistance genes was amplified. The highest resistance was to ceftazidime (98%), cefepime (86%), tetracycline (84%), levofloxacin (78%) and piperacillin-tazobactam (76%), while the highest sensitivity was to meropenem (63%) and tigecycline (62%). ESBL production was determined in 94% and carbapenemases were observed in 54% of A. baumannii. Four isolates (2%) were found to carry the mcr-1 gene, and three isolates (1.5%) were found to carry the mcr-2 gene. Moreover, the fosA3 was not detected in the isolates. This study showed that MDR A. baumannii was high in ICU settings. The spread of antibiotics considered the last line of defense against infections is a concern that necessitates surveillance and control measures.

BACKGROUND Artificial intelligence (AI) is increasingly explored as a clinical decision-support tool in nephrology; however, its real-world applicability for dialysis decision-making in emergency and intensive care unit (ICU) settings remains insufficiently studied. Hemodialysis initiation and prescription are complex, time-sensitive, and dynamic processes that require expert clinical judgment. MATERIAL AND METHODS This retrospective observational study evaluated agreement between AI-generated (ChatGPT) and nephrologist-made dialysis decisions in emergency and ICU settings. Adult patients undergoing first-time dialysis were included. Agreement was assessed for dialysis initiation, modality selection, and key prescription parameters. To ensure clinical relevance, continuous prescription variables were categorized into predefined ranges. Agreement was quantified using Gwet's AC1 coefficient and Cramer's V statistic. RESULTS Eighty-four patients were included. AI demonstrated 100% agreement with nephrologists regarding dialysis initiation. Overall agreement for dialysis modality selection was 92.9% (Cramer's V=0.87, P<0.001). Agreement for core dialysis prescription parameters - including blood flow rate, dialysate sodium, potassium, and calcium concentrations - was high across modalities (all P<0.001). Lower agreement was observed for ultrafiltration-related parameters, particularly ultrafiltration duration, reflecting the individualized and dynamic nature of volume management during dialysis. CONCLUSIONS AI-assisted decision support demonstrated high agreement with nephrologist decisions for initial dialysis initiation, modality selection, and core prescription parameters in emergency and ICU settings. Discrepancies were primarily confined to ultrafiltration-related decisions, underscoring the necessity of ongoing bedside clinical judgment. These findings support the role of AI as a decision-support tool rather than a replacement for clinician-led dialysis management.

Candida bloodstream infections: comparison of species distribution and resistance to echinocandin and azole antifungal agents in Intensive Care Unit (ICU) and non-ICU settings in the SENTRY Antimicrobial Surveillance Program (2008–2009)

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

Antibiotic Therapy of Ventilator-Associated Pneumonia: In Search of the Magic Bullet