Demographic and occupational data
On average, the physicians were 45 years old, with a SD of 12.6 years. The age distribution showed that 14.5% were under 30 years old, 26.9% were between 31 and 40 years old, 25.0% were between 41 and 50 years old, 19.5% were between 51 and 60 years old, and 14.1% were over 60 years old. In terms of gender, 47.0% were men and 53.0% were women. Regarding education, 11.3% were graduates, 13.5% were residents, and 75.2% were board-certified physicians. Additionally, 16.6% of the physicians were board certified in anaesthesiology and intensive medicine, while 83.4% were not. The participants work in various departments, with 30.2% in the Intensive and Resuscitation Care Unit, 59.9% in standard (non-intensive) departments, and 9.9% in Post-Acute Care Units (Aftercare units or departments). The type of facility they work in included 30.2% in teaching or faculty hospitals, 59.9% in regional hospitals, and 9.9% in rural hospitals.
A detailed presentation of the data on the study can be found in Table 1.
Providing a lower standard of care
The survey aimed to assess whether hospital physicians encountered situations where patients received a “lower standard of medical care” during the pandemic (Supplementary data, question 5). In this context, “lower standard of medical care” is defined as a scenario where a patient received fewer therapeutic procedures than would typically be administered under standard care in the pre-pandemic period. The definition of this term was established in a statement issued by the Czech Society of Anaesthesiology and Intensive Care Medicine (available only in the Czech language) and posted on the Czech Ministry of Health website [16]. The results reveal that over half of physicians reported that at least occasionally, they found themselves in a situation where they had to provide a “lower standard of medical care” to a patient (Fig. 1). Notably, a smaller percentage (less than 5%) encountered these situations daily. This data underscores the challenges faced by healthcare providers during the pandemic, with a substantial proportion experiencing instances where the care delivered was below the usual standard due to the strain on healthcare resources.
Reporting of a “lower standard of care”
Around 46% of physicians in the Anaesthesiology departments/ICU made decisions on limiting care in consensus with a multidisciplinary team, more than in standard departments, where only 11.4% reported using this approach.
A decision about healthcare
Physicians frequently perceive the decision to administer a “lower standard of care”, particularly in a scenario where more patients could realistically benefit from the “usual standard of care” based on EBM (Evidence-Based Medicine), as a dilemma of a medical and ethical nature rather than a legal concern (Supplementary data, question 9). About 20% of the responders could not define the nature of the question, whereas, in stark contrast, a significant 90% agreed or somewhat agreed with all the concerns mentioned, indicating the complexity and gravity of these decisions. (Fig. 2). Physicians answered each question separately with a degree of compliance.
Physicians’ perception of the decision to provide a “lower standard of care”
The data also revealed a gender difference in how these situations are viewed: male physicians are more likely to see it as a medical issue (p < 0.001), while female physicians are more inclined to consider it an ethical issue (p = 0.037), see Table 2. This suggests that perceptions of these challenging scenarios can vary significantly based on the physician’s perspective and possibly their experiences in clinical practice [17, 18]. Other results were not statistically significant.
The analysis of physician perspectives on ventilator allocation during shortages reveals a complex and multifaceted approach to decision-making in crisis scenarios (Supplementary data, question 10). Figure 3 illustrates the perspectives of physicians on the ethical and practical challenges of withholding artificial pulmonary ventilation during periods of ventilator shortage. The majority of respondents consider the situation as an ethical dilemma, with about 70% agreeing or rather agreeing that it is necessary to establish a predefined framework for decision-making. This indicates a strong consensus on the need for clear guidelines to navigate these difficult choices. Additionally, a significant proportion of physicians agree or rather agree with the full utilisation of available ventilators, reflecting a general inclination to maximise the use of scarce resources. However, there is considerable variation in views when it comes to patient categorisation and narrowing medical criteria. Approximately half of the respondents believe that categorisation should be relevant only when the last ventilator is available, suggesting a preference for delaying such decisions until absolutely necessary. Similarly, the idea of narrowing medical criteria to prioritise specific patient groups received mixed responses, with notable disagreement, indicating the contentious nature of this approach.
Physicians’ perception of the failure to provide ALV during ventilator shortages
Notably, female physicians are more inclined to support narrowing the criteria for ventilation (p = 0.001). Comparing hospital types, physicians from regional hospitals more frequently agree that only patients with the highest chance of survival should receive ventilators compared to those from teaching/university hospitals (p = 0.035) and other regional hospitals (hospitals at regional and district levels) (p = 0.014). This viewpoint is also observed when comparing residents to board-certified physicians. Conversely, all physicians working in and those from standard departments (non-intensive departments) are more inclined to support using ventilators to their total capacity (p = 0.004). Regarding decision-making on healthcare limitations, the consensus of attending physicians (54.4%) or a multidisciplinary team (24.3%) predominantly drive decisions. Other processes include the determination of shift supervisors (the chief physician of the department or the chief medical officer of the service) (15.6%) and the personal judgments of physicians (5.7%). The decision not to administer artificial lung ventilation or transfer patients to the ICU is jointly made by treating physicians and ICU physicians without any participation of patients or their families in the decision-making process regarding care, according to 70.9% of respondents. This collaborative decision-making process occurs occasionally or rarely, as 21% of physicians reported. It is more commonly seen among female physicians than male counterparts (p = 0.027). The most frequently reported reasons for not recommending ICU, artificial lung ventilation, or ECMO include a combination of comorbidities or anticipated short survival time (60%) (in the scope of the questionnaire, the meaning of “short” survival was not explicitly defined), high age (40%), malignancy (31%), and obesity (9%) (Fig. 4).
Reasons for advising against intensive care, artificial lung ventilation, or extracorporeal membrane oxygenation
Anaesthesiology and intensive medicine residents and fellows and physicians (residents, fellows, board-certified) from standard (non-intensive) departments more often agreed with allocating ventilators to their full use (p = 0.004). Half of the surveyed physicians (50.2%) experienced patient transportation refusal to higher facilities.
During the pandemic, communication between physicians and patients regarding care restrictions due to resource limitations varied significantly (Table 2). Nearly half of the physicians who treated patients with restricted care due to resource limitations communicated this situation to them (Table 2). In contrast, 25.4% of physicians indicated that they never informed the patient despite the patient being capable of receiving such information. Additionally, only 26.6% of physicians informed patients exceptionally.
Physicians in the anaesthesiology department, known for their higher standard of care, communicate with patients less frequently about a lower standard of care compared to those in standard departments. This distinction is significant, as most physicians in standard departments, including residents, fellows, and board-certified professionals, communicate a lower standard of care more often. In fact, only 42% of anaesthesiology department/ICU physicians engage in such communication.
Recent graduates, across all specialities, show a higher frequency of communication with patients about a lower standard of care compared to board-certified physicians (p = 0.0001) and board-certified physicians (p = 0.014). This finding suggests a potential for improvement and growth in these young professionals, offering hope for the future of healthcare. The findings also show a need for improving communication skills across all specialities regardless of years of practice.
Anaesthesiology residents, who were less experienced in their field, more often communicated a lower standard of care with patients compared to anaesthesiology fellows (p-value 0.0001) or board-certified anaesthesiologists (p-value 0.014), indicating that less experienced physicians may be more likely to engage with patients under a lower standard of care.
Furthermore, two-thirds of physicians shared this information with the patient’s family or a close associate. However, 18.7% of physicians did so only exceptionally, and 14.7% did not inform the family, believing it was inappropriate (Table 3). We lack data on the frequency at which patients were kept informed or how regularly they took part in the decision-making process.
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