Philosophical/Theoretical Paper

Nursing Ethics
2023, Vol. 0(0) 1–11
Ethical considerations in evaluating © The Author(s) 2023

discharge readiness from the Article reuse guidelines:

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intensive care unit DOI: 10.1177/09697330231212338
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Sang Bin You 

NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA

Connie M. Ulrich 
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA

Abstract
Evaluating readiness for discharge from the intensive care unit (ICU) is a critical aspect of patient care.
Whereas evidence-based criteria for ICU admission have been established, practical criteria for discharge
from the ICU are lacking. Often discharge guidelines simply state that a patient no longer meets ICU ad-
mission criteria. Such discharge criteria can be interpreted differently by different healthcare providers,
leaving a clinical void where misunderstandings of patients’ readiness can conflict with perceptions of what
readiness means for patients, families, and healthcare providers. In considering ICU discharge readiness, the
use and application of ethical principles may be helpful in mitigating such conflicts and achieving desired
patient outcomes. Ethical principles propose different ways of understanding what readiness might mean and
how clinicians might weigh these principles in their decision-making process. This article examines the
concept of discharge readiness through the lens of the most widely cited ethical principles (autonomy
[respect for persons], nonmaleficence/beneficence, and justice) and provides a discussion of their application
in the critical care environment. Ongoing bioethics discourse and empirical research are needed to identify
factors that help determine discharge readiness within critical care environments that will ultimately promote
safe and effective ICU discharges for patients and their families.

Keywords
ethical theory, intensive care units, patient discharge, principle-based ethics

Corresponding author:
Sang Bin You, University of Pennsylvania School of Nursing, Claire M. Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104-4217,
USA.
Email: sbyou@nursing.upenn.edu
2 Nursing Ethics 0(0)

Introduction
An intensive care unit (ICU) is a highly specialized unit where critical care, including various life-saving
treatments, is provided. In a fast-aging society with rapid advancements in medicine, the demand for critical
care beds has been increasing exponentially.1 However, due to the limited availability of ICU beds and
other resources, patients may be rushed out of the ICU before they are adequately prepared for the next
lower level of care (e.g., general floor and step-down unit).2,3 The allocation problem of limited medical
resources was keenly felt during the SARs-CoV-2 virus (COVID-19) outbreak.4,5 During this time, the need
for ventilators, ICU beds, dialysis machines, and other critical care resources was high, and allocating these
scare resources without guidelines was distressing for many healthcare providers. Indeed, the COVID-19
pandemic highlighted an extreme resource allocation challenge, necessitating immediate consideration of
fundamental ethical frameworks to guide the distribution of scare resources by healthcare providers and by
the institutions in which they worked. Further, because of continued limited ICU resources, resource
allocation remains an important factor in determining patients’ discharge readiness, even after the peak of
the pandemic. This has important clinical and ethical implications because multiple values are often
considered in the moral decision-making process within the ICU, given the complexity and competing
priorities among key stakeholders.
Discharge readiness is an important overall health outcome indicator.6 As such, discharging patients from
the ICU before they are ready can result in longer hospital stays, increased readmissions, higher mortality, and
increased healthcare costs.1,7 On the other hand, providers want to avoid keeping patients in the hospital
beyond what is necessary, because prolonged hospitalization increases the risk of hospital complications and
raises healthcare costs.8,9 Evidence suggests that care transitions are vulnerable moments when adverse
events, medical errors, increased mortality, and higher healthcare costs can occur.10–12

Current Guidelines
In 2016, the Society of Critical Care Medicine (SCCM) established evidence-based recommendations for ICU
admission, discharge, and triage (ICU ADT) to promote safe and effective healthcare for critically ill
patients.13,14 Although SCCM recommends that hospitals establish discharge criteria, the guidelines do not
provide specific components for such criteria.13,15 Current guidelines define ICU discharge criteria as when
patients no longer meet the criteria for ICU admission; that is, the SCCM guidelines state that ICU patients can
be discharged when their physiological condition has stabilized and active ICU care and surveillance are no
longer necessary.13 ICU admission criteria include a combination of specific needs for life-supportive
therapies, availabilities for clinical expertise and resources, and potential benefits from ICU admission.13
These criteria are ambiguous and often dependent on context-specific situations, leaving room for healthcare
providers and institutions to determine what to prioritize and what factors to consider in discharge-related
decisions. Thus, such decisions can be highly subjective and not always as transparent as they should (or
could) be for everyone involved.
Although the SCCM ICU ADT guidelines recommend following the American Thoracic Society (ATS)’s
official statement on fair allocation of ICU resources,16 they do not delve into the specifics of how these
strategies impact the allocation process or which principles should be prioritized. Additionally, ATS’s
principles and positions regarding fair allocation of ICU resources are listed in the SCCM ICU ADT
guidelines, but neither document provides clear guidance for providers on how to prioritize or make decisions
during this process. The ATS statements supported by SCCM ICU ADT guidelines advise considering both
macro-level (policy level) and micro-level (individual level) decisions. In one section of the document, it
briefly discusses the connection between fair allocation and ICU discharge readiness. It explains that
in situations where ICU resources are limited or fully utilized, or when the perceived need for these resources
You and Ulrich 3

significantly exceeds their supply, patients admitted to an ICU may not receive all the necessary resources.
This, in turn, can potentially lead to suboptimal discharges. However, the ATS’s section on fair allocation does
not specifically detail how this might impact ICU discharge decisions. Considering that the SCCM ICU ADT
guidelines have not been updated since 2016 and the ATS guidelines for fair allocation were established in
1997, predating the COVID-19 pandemic, there is an evident need for a comprehensive update not only in the
context of resource allocation but overall. It is crucial to shift more focus toward ICU discharge criteria, as this
not only ensures the safe transition of ICU survivors to the next level of care, preventing ICU readmission but
also plays a pivotal role in making ICU resources available for others in need.
Although guidelines have shown effectiveness in reducing ICU length of stay and improving resource
utilization, only a limited number of ICUs have implemented written patient discharge guidelines, and
even among those that have, their consistent implementation in practice has varied.15,17–19 Previous
studies have identified factors associated with successful ICU discharge, including discharge education
for patients and families, assessing and meeting patient/family needs, efficient communication among
providers-providers/providers-patients, and use of discharge guidelines created by the clinicians’
healthcare institution.1,10,18

Ethical Frameworks
During the COVID-19 pandemic, several authors discussed the importance of ethical frameworks that
specifically addressed the public health crisis and the processes and practices surrounding discharge and
transfer of patients.20,21 These frameworks primarily concentrated on managing the uncertainty and day-to-
day ethical decisions that clinicians were facing in allocating scarce resources. With an emphasis on
decisions for rationing ventilatory support in critical care, White and Lo examined the challenges of
choosing which patients to treat first when there are few resources.20 The focus is often on survival through
hospital discharge, which they argued is not ethically sufficient, supporting further discussions on allo-
cating resources from one patient to another and a multiprinciple allocation approach. Such an approach
advocates the integration of multiple criteria. For example, when determining ventilator allocation
in situations where not all patients can receive one, factors to be considered include patients’ in-hospital
survival, longer-term survival (after hospital discharge), the role of individuals in overall public health, and
the life-cycle principle.
Clinical judgment in decision-making is not void of ethical values that can inform and guide clinicians in
difficult and taxing patient care situations.22,23 These bioethical underpinnings allow clinicians to consider
a variety of ethical principles and theoretical perspectives, including the well-known ethical principles
defined by Beauchamp and Childress.24 This article examines how clinicians and others can view discharge
readiness on the basis of Beauchamp and Childress’s ethical principles and factors that are
emphasized when evaluating ICU discharge readiness.24 Together, the four principles discussed below
(autonomy[respect for persons], nonmaleficence/beneficence, and justice) form a useful ethical
perspective/framework for informing ICU discharge readiness decisions. Each principle brings to the fore
different factors for consideration, and depending on which factors are prioritized in determining discharge
readiness and desired outcomes, each principle may lead to a different conclusion regarding discharge.
When conclusions are taken together and weighed, the ethical principles can help guide clinical decisions in
difficult discharge contexts.
Through discussion of each ethical principle and the factors it brings to the fore, the authors discuss areas
for improvement in current ICU discharge guidelines and provide suggestions for a comprehensive evaluation
of ICU discharge readiness. These suggestions could open the door for further discussion and reevaluation of
current standards within the critical care community.
4 Nursing Ethics 0(0)

Application of Bioethical Principles to Discharge Readiness

Autonomy or Respect for Persons
The principle of autonomy—or respect for persons—recognizes that individuals have the right to make
autonomous decisions regarding their health and well-being and also provides safeguards for those who do
not have the ability to contribute to or to make decisions about their treatments.25 The medical paradigm of
patient- family- and person–centered care also advocates for the involvement of patients in their care.26
Because patient autonomy is a foundational and guiding ethical principle in healthcare, patients should be
able to make decisions that advocate for themselves and align with their values and priorities. However,
patients’ agency is often constrained by their serious illness and by the imbalanced power dynamics between
patients and healthcare clinicians.27 Shared decision-making is often advocated as a model of deliberation,
communication, and engagement between patients and their clinicians within the clinical arena but there are
some patients who prefer a passive role in this relationship.28,29 Passivity can be influenced by the power
hierarchy that often positions healthcare providers in a more influential position. For example, there are
situations where patients find it challenging to question or challenge healthcare providers’ decisions, par-
ticularly when their well-being or care is dependent on those decisions.28,30–32 Nonetheless, it is ethically
ideal to provide ICU patients with the ability to communicate their preferences when they have the cognitive
capacity to do so.
Understandably, patients and their surrogates may have different priorities and values for the goals of care
during evaluation for ICU discharge. For example, some patients may prioritize their physical condition over
their psychological/mental condition, whereas their surrogates may prioritize the opposite or consider other
factors based on their prior experiences or personal values. To date, ICU discharge criteria mainly focus on
physiological readiness,13 but patients and their surrogates may have a wide range of expectations for the
patient’s physical, psychological, mental, and functional conditions upon ICU discharge.
While it is necessary to honor and incorporate the values and perspectives of patients and their surrogates
regarding discharge readiness, healthcare professionals also have a responsibility to advocate for what is in
their patient’s best interest. Clinicians must carefully weigh the risk of harm to patients if they are directly
discharged from the ICU to their home or another setting without adequate at-home or community resources,
including a reliable caregiver,33,34 or when the patient and their family want to stay in the ICU for closely
monitored care even after they do not necessarily need such care.35 More research is needed to gain a better
understanding of how patients, their surrogates, and healthcare clinicians perceive discharge readiness and the
role of autonomy in those decisions and the tensions that may exist.

Nonmaleficence and Beneficence

The principle of nonmaleficence urges healthcare providers not to inflict any harm or injury on patients.24
When considering the principle of nonmaleficence, healthcare providers must prioritize the obligation to
avoid causing harm to patients. Medical treatments may have both benefits and risks; however, healthcare
providers should refrain from making decisions that knowingly result in more harm than good for their
patients. The discharge of a patient from the ICU earlier than warranted in order to prioritize care for a more
critically ill patient could be considered as indirectly inflicting harm on the discharged patient. In this
situation, the healthcare provider may not have established a therapeutic patient-provider relationship to
provide care to the incoming patient. An often-cited concept is a clinician’s “duty to care”—or moral re-
sponsibility for the patient already in that clinician’s care.
The SCCM’s ICU discharge guidelines focus only on physiological status without considering other
conditions (e.g., cognitive and mental conditions),13 which has the potential to cause harm to patients because
You and Ulrich 5

incomplete discharge assessments can lead to adverse outcomes.6,7 In order to prevent adverse outcomes (i.e.,
readmission, mortality) after ICU discharge, it is crucial to consider patients’ overall functional status,
including physical, cognitive, and mental conditions, when assessing the potential harms associated with their
discharge. This consideration should be independent of other factors, such as resource availability, the care
needs of other patients, or the ICU patient’s wishes. Post-intensive care syndrome (PICS), a cluster of
complications in physical, cognitive, and mental domains, is common and observed in up to 70% of ICU
survivors.36–38 Given the high incidence of PICS, it is essential to assess and take into account the potential
development of such complications when determining ICU discharge readiness. Failure to evaluate antic-
ipated complications after ICU discharge can result in harm to patients, with long-lasting effects. Therefore,
considering only one aspect of a patient’s condition, such as physical, cognitive, or mental, when determining
discharge readiness may contradict the principle of nonmaleficence, because it overlooks other aspects of the
patient’s status that are not yet stabilized or that need continuous monitoring.
Decisions on who will receive ICU care are often made based on speculations such as predictions of a
patient’s prognosis and of possible treatment response or lack of response. Such speculations are based on
providers’ best clinical judgment, which is grounded in data and experience. Providers often allocate limited
resources to patients they deem likely to have a higher chance of survival and a better prognosis following
ICU care. However, there are no certainties in medicine and always risks of harm. Therefore, even the most
well-considered decisions may not lead to a predicted outcome for an individual patient, and patients who are
deemed to have a lower chance of survival nevertheless do have a chance of survival. Each patient is unique,
with a different disease trajectory, and providers cannot know whether patients who did not receive extended
ICU care may have responded in an unpredicted way or have lived longer if such care was provided.
Therefore, from the perspective of nonmaleficence, clinicians may inflict harm on patients by not providing
ICU care, and some ICU discharge decisions could be seen as unethical because they violate the principle of
nonmaleficence—not because providers or hospitals actively or directly cause harm but because such de-
cisions may lead to readmission and other complications over a longer time frame.39
Closely related to the ethical principle of nonmaleficence is the principle of beneficence. Indeed, healthcare
providers have a duty to act in the best interest of their patients.24 In other words, the principle of beneficence
entails promoting the health and well-being of patients and striving to do good on their behalf. Non-
maleficence focuses on intentionally avoiding activities that may harm patients, whereas beneficence seeks to
balance benefits and burdens to achieve the best possible outcome for patients.40
The principles of beneficence and nonmaleficence both aim to prevent harm to patients, one by promoting
good and the other by avoiding harm, and both need to be considered in making decisions about ICU
discharge. For examdple, ICU discharge criteria would typically assess the comprehensive condition of
patients, encompassing physical, cognitive, mental, and social well-being, in order to prevent known and
predicted adverse outcomes. However, nonmaleficence entails an absolute obligation to avoid harm under all
circumstances, whereas promoting good, as per the principle of beneficence, may not be an absolute re-
quirement in all circumstances. A provider may not have a moral responsibility for a patient with whom the
provider has not yet developed a special relationship. For example, an ICU provider has no special
obligation—no provider-patient relationship—with a patient waiting for ICU admission because that patient
is not yet under the provider’s care. However, providers are still encouraged to promote goodness and provide
assistance to others.40 Thus, when evaluating one patient’s discharge readiness while another patient is
waiting for ICU admission, competing needs may surface when making decisions about how to promote the
best outcomes for both patients. The principle of nonmaleficence would focus on avoiding harm to the
existing ICU patient, with whom the provider has a provider-patient relationship. However, from the
perspective of beneficence in the context of limited availability of ICU resources, discharge readiness
decisions would take into account the best health outcomes for patients beyond the boundaries of the ICU.
6 Nursing Ethics 0(0)

Justice
In healthcare, justice is commonly equated with distributive justice or the fair distribution of scarce re-
sources.41 The decision to admit or discharge a patient is not problematic when resources are abundant, but it
becomes challenging when resources are scarce. As noted above, ethical issues surrounding resource al-
location, specifically distributive justice, became prominent during the COVID-19 pandemic. In addition,
readiness for discharge is often evaluated in the context of resource allocation. ICU beds and critical care
resources continue to be limited, and demands for such care have increased in light of an aging population and
increased severity of illness.42
The SCCM ICU ADT guidelines consider institutional resource availability, such as ICU beds and
life-supportive resources, but do not provide guidance on how to evaluate and distribute these limited
resources. Efforts have been made to provide guidance for allocating scare resources during the pan-
demic, aiming to assist healthcare clinicians and communities in managing limited resources during a
global health crisis. Various strategies have been suggested to aid in developing triage protocols for
resource allocation decisions, with a focus on predicting in-hospital mortality, short-term mortality
(typically within 1 year), and near-term mortality (usually within 5 years), and maximizing the number of
saved life-years.43 For instance, acute illness scores, such as the Sequential Organ Failure Assessment
(SOFA) score, have often been utilized to allocate resources by predicting patients’ mortality. However,
the accuracy of SOFA in predicting mortality varies44,45 which may cast doubt on its reliability as a basis
for resource allocation.46
Another widely employed resource allocation strategy involves considering life-years saved, thus pri-
oritizing patients who would benefit from more “life-years saved.” Age was often used as a tiebreaker when
patients had similar medical conditions and required similar resources.47 Nevertheless, concerns have been
raised about the reliability of long-term life expectancy prognostication.48 It is important to note that these
strategies were not specifically designed for ICU discharge decisions (i.e., reallocating resources from one
patient to another); rather, they were intended to guide the allocation of necessary resources to patients in need
of treatments and resources (i.e., determining who should receive the resources). The allocation of ICU
resources plays a crucial role in a patient’s outcome, making it a critical matter that requires careful con-
sideration. To incorporate resource availability as part of discharge criteria, the ethical principle of justice
should be considered. Ensuring ethical and fair distribution of limited resources is crucial to preventing
reliance solely on social determinants of health.
Making moral decisions about resource allocation in complex situations typically involves many values
and competing priorities. Four fundamental values are commonly employed strategies for resource allocation:
(1) maximizing benefits produced from scarce resources, (2) equal treatment of people, (3) promotion and
compensation of instrumental value, and (4) giving priority to those most vulnerable or in need.49 Along with
these values, factors such as age, clinical condition, expected effectiveness of treatment, and predicted
survival rate are also often considered in the resource allocation decision-making process.49
Readiness for ICU discharge could be evaluated differently depending on the conditions of other patients
and the availability of resources at healthcare institutions. Even if the condition of two ICU patients is similar,
decisions about discharge may be influenced by the condition of other patients waiting for ICU admission or
access to ICU resources. For instance, if a patient waiting for ICU admission has a more severe clinical
condition but a higher chance of survival than a current ICU patient, the ICU patient may be discharged earlier
than expected, even if that patient is still recovering from deteriorated physiological status. On the other hand,
an ICU patient may continue to receive ICU care if they have a higher medical priority compared with that of a
waiting patient. Additionally, there may be instances where ICU discharge is delayed due to the limited
availability of resources in a lower acuity area, such as wards, step-downs, or long-term care facilities, which
can result in overutilization of the ICU and avoidable use of ICU days. Therefore, evaluating ICU patients’
You and Ulrich 7

readiness for discharge is highly dependent on the availability of resources in the next level of care and the
clinical condition of the patients with whom they are being compared. Thus, when viewing ICU discharge
decisions from a justice lens, it is important to acknowledge that factors beyond the patient’s current medical
condition can impact the determination of ICU discharge readiness.
John Rawls, a prominent American political philosopher, has argued that achieving distributive justice is
contingent upon the establishment of a nation or institution based on fair principles.41 Rawls proposed a
hypothetical negotiation scenario aimed at constructing a fair social institution.41 He argued that the in-
dividuals within society would choose fair social orders when they were behind the “veil of ignorance,”
wherein they are hypothetically blinded to their assigned community, wealth, abilities, or social standings.41
These principles, formulated without bias, would be fair and respectful to all members of society. Although
Rawls originally applied his concept to testing the principle of a nation, it could also be applied to an
institutional context.50 Rawls might argue that achieving distributive justice in the allocation of medical
resources is fundamentally challenging due to the inherent inequalities within the US health system.51 For
example, access to medical treatments is often limited to those who can afford them, and some patients may
decline necessary ICU care due to the financial burden.51 Additionally, hospitals vary greatly in terms of
resource availability, such as the number of beds, ventilators, and healthcare professionals, which can impact
patient outcomes. Proximity to well-equipped hospitals can also affect the quality of care received as well as
health outcomes.52,53 If hospitals had more resources, decisions to discharge a patient earlier than may be
warranted in order to achieve a fair allocation of limited resources could be reduced.54 Thus, from Rawls’
perspective, achieving distributive justice solely through resource allocation is difficult due to the underlying
inequality in how patient access to medical care is structured within hospital systems. In upholding the ethical
principle of justice, distributive justice would be achieved by considering both patient-related characteristics
and the availability of institutional resources.

Discussion
Intensive care unit (ICU) is where critical and intensive care is provided. Patients who are considered for
ICU admission or who are receiving ICU care are often in a life-or-death situation. As noted above, the
decision to admit or discharge a patient becomes challenging when resources are scarce. Therefore, ICU
discharge decisions should consider patient outcomes as well as the allocation of limited resources. In such
circumstances, criteria are needed to guide healthcare providers in making informed decisions. There is no
one-size-fits-all guideline for making ICU discharge decisions, and thus there is room for variability, taking
into consideration complex real-life cases. However, even if a guideline is unable to provide step-by-step
detailed criteria, it should describe factors to be considered, as well as strategies or resources that can be
used.
Current guidelines for assessing ICU discharge readiness may simply state that a patient no longer meets
ICU admission criteria, and as such the guidelines allow room for interpretation. Healthcare providers
comprehensively evaluate ICU discharge readiness based on their clinical judgment and ethical principles or
values that they or their institution prioritize. ICU nurses, for example, are constantly monitoring patients
under their care and assessing patients’ discharge readiness, although they may not be directly involved in
those decisions. During the pandemic, ICU nurses who provided care for the most critically ill patients faced a
multitude of challenges, including the significant issue of ventilator shortages and transitioning patients in and
out of the ICU.55 More discussion is needed on nurses’ involvement in these decisions and the factors they
prioritize when considering discharge readiness of their patients.
In addition to a patient’s health status and conditions and therapeutic efficacy, decision factors include
patient and family care preferences and bioethical perspectives.56 Bioethical principles to consider are fair
resource distribution, the provider’s obligation to not cause harm, patient advocacy, and patients’ wishes.
8 Nursing Ethics 0(0)

With the shift in recent decades toward patient- and family-centered care in the healthcare paradigm, it is
important to actively involve patients and their care partners in the planning, delivery, and evaluation of the
healthcare process.26 Therefore, when making decisions about ICU discharge, it is important to actively
communicate with patients and families to understand their priorities and values in care and involve them in
the decision-making process. However, in cases where the values of patients and providers conflict (i.e.,
autonomy vs nonmaleficence), providers need to carefully balance the different ethical principles. It is
important to discuss potential post-ICU complications (e.g., PICS and ICU-acquired weakness) with
patients and families to support informed discharge decisions and enable early detection and timely
intervention.
When determining a patient’s ICU discharge readiness, providers should keep in mind that patients are in
the care continuum. ICU discharge should not be viewed as the ultimate goal, but rather as a transitional
moment that marks the beginning of a new care trajectory for patients. This perspective allows healthcare
providers to have a broader understanding of the continuum of care and consider comprehensive factors that
contribute to improved patient outcomes following ICU discharge.

Conclusion
Timely ICU discharge reduces preventable mortality and readmission while decreasing unnecessary
healthcare costs. However, as there are currently no practical and standardized ICU discharge criteria,
variability in providers’ interpretations of competing priorities may play a prominent role in determining a
patient’s discharge readiness. This article has explored how discharge readiness is defined in the ICU and how
evaluation of discharge readiness could look different when viewed through the lens of various bioethical
principles. No single principle can—or should—drive the discharge decision, but consideration of the
principles of patient autonomy [respect for persons], nonmaleficence/beneficence, and justice can help guide
providers toward more comprehensive assessments. To comprehensively evaluate ICU discharge readiness,
providers must take into account not only various dimensions of health (not limited to the physiological
aspect) but also patient values, the professional and ethical obligations as healthcare providers, and resource
availability at the hospital level. ICU discharge decisions are inherently complex, and the consideration of
bioethical principles discussed in this paper can provide valuable guidance to help providers navigate these
complexities and support well-informed decisions.

Acknowledgements
The authors would like to acknowledge and appreciate Drs. Kathryn Bowles, Pamela Cacchione, and Sara Jacoby for their
invaluable guidance, feedback, and support in this work.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs
Sang Bin You  https://orcid.org/0000-0002-1424-4140
Connie M. Ulrich  https://orcid.org/0000-0001-5681-3463
You and Ulrich 9

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