Article Text

other Versions

Download PDFPDF
Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool
  1. Bo Van den Bulcke1,
  2. Ruth Piers2,
  3. Hanne Irene Jensen3,4,
  4. Johan Malmgren5,
  5. Victoria Metaxa6,
  6. Anna K Reyners7,
  7. Michael Darmon8,
  8. Katerina Rusinova9,
  9. Daniel Talmor10,
  10. Anne-Pascale Meert11,
  11. Laura Cancelliere12,
  12. Làszló Zubek13,
  13. Paolo Maia14,
  14. Andrej Michalsen15,
  15. Johan Decruyenaere1,
  16. Erwin J O Kompanje16,
  17. Elie Azoulay17,
  18. Reitske Meganck18,
  19. Ariëlla Van de Sompel19,
  20. Stijn Vansteelandt19,
  21. Peter Vlerick20,
  22. Stijn Vanheule21,
  23. Dominique D Benoit1
  1. 1Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
  2. 2Geriatrics, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
  3. 3Department of Anaesthesiology and Intensive Care, Sygehus Lillebælt Vejle Sygehus, Vejle, Denmark
  4. 4Institute of Health Research, University of Southern Denmark, Odense, Denmark
  5. 5Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
  6. 6King’s College Hospital, London, UK
  7. 7Department of Medical Oncology, University of Groningen, Groningen, Netherlands
  8. 8Medical-Surgical Intensive Care Unit, Hopital NordSaint-Etienne University Hospital, Saint-Etienne, France
  9. 9Department of Anaesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
  10. 10Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
  11. 11Service des Soins Intensifs et Urgences Oncologiques, Institut Jules Bordet, ULB, Bruxelles, Belgium
  12. 12SCDU Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria, ’Maggiore della Carità', Novara, Italy
  13. 13Department of Anesthesiology and Intensive Therapy, Semmelweis University Budapest, Budapest, Hungary
  14. 14Department of Intensive Care, Hospital de Santo António, Porto, Portugal
  15. 15Department of Anaesthesiology and Critical Care Medicine, Tettnang Hospital, Tettnang, Germany
  16. 16Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
  17. 17Medical Intensive Care Unit, Hôpital Saint-Louis and University Paris-7, Paris, France
  18. 18Department of Psychoanalysis and Clinical Consulting, Ghent University, Ghent, Belgium
  19. 19Department of Applied Mathematics, Computer Sciences and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium
  20. 20Department of Personnel Management, Work and Organizational Psychology, Ghent University, Ghent, Belgium
  21. 21Department of Psychoanalysis and Clinical Consulting, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
  1. Correspondence to Ms. Bo Van den Bulcke, Ghent University Hospital, Ghent 9000, Belgium; bo.vandenbulcke{at}


Background Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU).

Objectives To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates.

Methods Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups.

Results Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner.

Conclusions The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians’ behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.

  • communication
  • teamwork
  • critical care
  • decision-making

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors All authors had their substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data, drafting the work or revising it critically for important intellectual content and their final approval of the version published. Every author gave his/her agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This study was funded by Research Foundation Flanders (FWO) (10.13039/501100003130) and grant number 1800513N.

  • Competing interests None declared.

  • Ethics approval The ethics committees of all participating centres and the Danish National Health Authorities.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Linked Articles