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Keywords: Intensive care triage, Decision-making, Intensive care resource allocation, Intensive care unit admissions

ObjectiveTo assess the experience of moral distress among intensive care unit (ICU) professionals in the UK.DesignMixed methods: validated quantitative measure of moral distress followed by purposive sample of respondents who underwent semistructured interviews.SettingFour ICUs of varying sizes and specialty facilities.ParticipantsHealthcare professionals working in ICU.Results227 questionnaires were returned and 15 interviews performed. Moral distress occurred across all ICUs and professional demographics. It was most commonly related to providing care perceived as futile or against the patient’s wishes/interests, followed by resource constraints compromising care. Moral distress score was independently influenced by profession (p=0.02) (nurses 117.0 vs doctors 78.0). A lack of agency was central to moral distress and its negative experience could lead to withdrawal from engaging with patients/families. One-third indicated their intention to leave their current post due to moral distress and this was greater among nurses than doctors (37.0% vs 15.0%). Moral distress was independently associated with an intention to leave their current post (p<0.0001) and a previous post (p=0.001). Participants described a range of individualised coping strategies tailored to the situations faced. The most common and highly valued strategies were informal and relied on working within a supportive environment along with a close-knit team, although participants acknowledged there was a role for structured and formalised intervention.ConclusionsMoral distress is widespread among UK ICU professionals and can have an important negative impact on patient care, professional wellbeing and staff retention, a particularly concerning finding as this study was performed prior to the COVID-19 pandemic. Moral distress due to resource-related issues is more severe than comparable studies in North America. Interventions to support professionals should recognise the individualistic nature of coping with moral distress. The value of close-knit teams and supportive environments has implications for how intensive care services are organised.

Acute Respiratory Distress Syndrome (ARDS) is a devastating pulmonary inflammatory disorder, commonly precipitated by sepsis. Glucocorticoids are immunomodulatory steroids that can suppress inflammation. Their anti-inflammatory properties within tissues are influenced by their pre-receptor metabolism and amplification from inactive precursors by 11β-hydroxysteroid dehydrogenase type-1 (HSD-1). We hypothesised that in sepsis-related ARDS, alveolar macrophage (AM) HSD-1 activity and glucocorticoid activation are impaired, and associated with greater inflammatory injury and worse outcomes. We analysed broncho-alveolar lavage (BAL) and circulating glucocorticoid levels, AM HSD-1 reductase activity and Receptor for Advanced Glycation End-products (RAGE) levels in two cohorts of critically ill sepsis patients, with and without ARDS. AM HSD-1 reductase activity was also measured in lobectomy patients. We assessed inflammatory injury parameters in models of lung injury and sepsis in HSD-1 knockout (KO) and wild type (WT) mice. No difference in serum and BAL cortisol: cortisone ratios are shown between sepsis patients with and without ARDS. Across all sepsis patients, there is no association between BAL cortisol: cortisone ratio and 30-day mortality. However, AM HSD-1 reductase activity is impaired in patients with sepsis-related ARDS, compared to sepsis patients without ARDS and lobectomy patients (0.075 v 0.882 v 0.967 pM/hr/10 AMs, p=0.004). Across all sepsis patients (with and without ARDS), impaired AM HSD-1 reductase activity is associated with defective efferocytosis (r=0.804, p=0.008) and increased 30-day mortality. AM HSD-1 reductase activity negatively correlates with BAL RAGE in sepsis patients with ARDS (r=-0.427, p=0.017). Following intra-tracheal lipopolysaccharide (IT-LPS) injury, HSD-1 KO mice demonstrate increased alveolar neutrophil infiltration, apoptotic neutrophil accumulation, alveolar protein permeability and BAL RAGE concentrations compared to WT mice. Caecal Ligation and Puncture (CLP) injury in HSD-1 KO mice results in greater peritoneal apoptotic neutrophil accumulation compared to WT mice. AM HSD-1 reductase activity does not shape total BAL and serum cortisol: cortisone ratios, however impaired HSD-1 autocrine signalling renders AMs insensitive to the anti-inflammatory effects of local glucocorticoids. This contributes to the decreased efferocytosis, increased BAL RAGE concentrations and mortality seen in sepsis-related ARDS. Upregulation of alveolar HSD-1 activity could restore AM function and improve clinical outcomes in these patients.

In September 2019, before the pandemic, the Faculty of Intensive Care Medicine published guidance on decision making, advance care planning, and end-of-life care.2 This included a three stage decision making tool from the University of Warwick enabling clinicians to gather evidence, identify outcomes, and implement individualised care plans.3 Decision making for escalation of treatment (Warwick model) Funded by the National Institute for Health Research In the first week of March 2020, a multi-professional working group led by the Royal College of Physicians of London developed four strands of guidance for the management of patients with covid-19: The clinical decision making framework was intended for use not only during the pandemic but in all circumstances, countering suggestions of reactive rationing.1 This guidance was followed by an ethical framework for frontline staff working with covid-19, prepared by the committee on ethical issues in medicine of RCP London and supported by many other professional organisations, and openly available online from late March 2020.4 While there are undoubtedly opportunities to further develop and disseminate the guidance, particularly with our growing understanding of covid-19, it is a credit to the professional bodies that they were able to collaboratively prepare such support for front line clinicians at very short notice. Competing interests: JFC is chair of the End-of-Life Working Group, Faculty of Intensive Care Medicine and Royal College of Anaesthetists and Faculty of Intensive Care Medicine representative for National Audit for Care at the End of Life.

Background Mechanical chest compression devices consistently deliver high-quality chest compressions. Small very low-quality studies suggest mechanical devices may be effective as an alternative to manual chest compressions in the treatment of adult in-hospital cardiac arrest patients. The aim of this feasibility trial is to assess the feasibility of conducting an effectiveness trial in this patient population. Methods COMPRESS-RCT is a multi-centre parallel group feasibility randomised controlled trial, designed to assess the feasibility of undertaking an effectiveness to compare the effect of mechanical chest compressions with manual chest compressions on 30-day survival following in-hospital cardiac arrest. Over approximately two years, 330 adult patients who sustain an in-hospital cardiac arrest and are in a non-shockable rhythm will be randomised in a 3:1 ratio to receive ongoing treatment with a mechanical chest compression device (LUCAS 2/3, Jolife AB/Stryker, Lund, Sweden) or continued manual chest compressions. It is intended that recruitment will occur on a 24/7 basis by the clinical cardiac arrest team. The primary study outcome is the proportion of eligible participants randomised in the study during site operational recruitment hours. Participants will be enrolled using a model of deferred consent, with consent for follow-up sought from patients or their consultee in those that survive the cardiac arrest event. The trial will have an embedded qualitative study, in which we will conduct semi-structured interviews with hospital staff to explore facilitators and barriers to study recruitment. Discussion The findings of COMPRESS-RCT will provide important information about the deliverability of an effectiveness trial to evaluate the effect on 30-day mortality of routine use of mechanical chest compression devices in adult in-hospital cardiac arrest patients. Trial registration ISRCTN38139840 , date of registration 9th January 2017.

The acute respiratory distress syndrome (ARDS) is an important cause of respiratory failure in critically ill patients characterised by severe inflammation within the lungs. This inflammation is limited by anti-­inflammatory glucocorticoid hormones released from the hypothalamus-pituitary-adrenal (HPA) system. This thesis reports a series of investigations into glucocorticoid concentrations and glucocorticoid metabolism within the lungs of patients with ARDS. It also contains an investigation into a potential biomarker for ARDS. Our study of glucocorticoid concentrations in alveolar epithelial lining fluid showed increased cortisol concentrations within the lungs at onset of ARDS. These concentrations have a positive relationship with critical illness severity indices, but negative relationships with alveolar permeability and alveolar neutrophil counts. In peripheral tissues cortisone and cortisol are inter-converted by iso-­enzymes of 11β-­hydroxysteroid dehydrogenase (11β-­HSD). We have shown that healthy primary resident alveolar macrophages increase their production of active cortisol by the oxo-­reduction of inactive cortisone in response to inflammatory stimuli. Alveolar macrophages are responsible for the removal of spent and apoptotic inflammatory cells, failure of this process causes further inflammation. We have shown that glucocorticoids increase the rate of uptake of apoptotic cells by alveolar macrophages, and that macrophage 11β-HSD production of cortisol increases this process. We have shown however that alveolar macrophages extracted from patients with established ARDS have decreased 11β-HSD oxo-reductase activity. This decreased conversion of cortisone to cortisol will cause a diminished response to the anti-inflammatory signal of the HPA system. The implications of this are that they will have a limited capacity to up-­regulate efferocytosis and a diminished anti-­inflammatory potential. The receptor for advanced glycation end-­products (RAGE) is a potential biomarker in ARDS. We have shown that RAGE concentrations in plasma and BALF had excellent diagnostic compatibility with ARDS diagnostic criteria. The use of a threshold RAGE concentration could assure pulmonary inflammation in future investigations.

Indeed, we seem to be determined to denigrate our most obvious accomplishments in the last war: The driving willpower of our commanders is dismissed as boorishness and egotism; arcane technical reports are deconstructed by technological illiterates to demonstrate how our high-tech weapons - despite the evidence of our eyes and of the outcome of combat - didn't work. The merciful resolution to end the slaughter is dismissed as a PR move to sell a slickly packaged \"Hundred-Hour War.\" The suspicion remains that our motives are not so respectable. In fact, it may be an error even tospeak of \"our\" and \"us.\" There is precious little sense of \"us\" in a nation that has come to worship the new ideal of autonomous individuality. Given human nature, this translates all too easily into a society of all against all, where each individual's 15 minutes of fame leads inevitably to 15 minutes of public humiliation. It does not help that our technological genius has brought us to a state of information overload. The excruciating if often erroneous detail with which we think we know our leaders breeds a phenomenal contempt. As someone said, \"No man is a hero to his valet.\"

THE IMMINENT kickoff of Operation Restore Hope in Somalia provokes a great many fascinating questions. In the dark niches of the American national psyche where the Vietnam Syndrome lurks, still alive and well despite premature announcements of its demise, the question that resonates loudest is: \"Can we get out?\" Otherwise, in the words of one vociferous critic of the operation, Operation Restore Hope will \"keep tens of thousands of Somali kids from starving to death in 1993 who, in all probability, will starve to death in 1994.\" The same critic argues Somali gunmen will \"withdraw into the interior, out of range of UN guns,\" but such visions of a guerrilla war against American occupiers are far-fetched. To be out of range of UN guns means being out of range of UN food, and many gunmen are already starving. The fact is that an outright American failure in Somalia is unlikely, unless the Somali people are truly bent on self destruction. Might may not make right, but having sufficient might sometimes imposes that awkward obligation to do right. There is no ethical alternative to acting.