Authors: Chacko C et al.
Cureus, June 18, 2026.
Summary
This cross-sectional study examined how consistently healthcare professionals make intensive care unit admission decisions, what factors influence those decisions, and how much stress clinicians experience during the process.
The study surveyed 83 ICU professionals from five National Health Service hospital systems in the West Midlands, United Kingdom. Participants reviewed 10 standardized clinical vignettes representing patients who might be referred for ICU admission.
Participants were divided into two groups:
• Decision-makers: ICU consultants and senior ICU physicians
• Non-decision-makers: junior physicians, nurses, non-ICU doctors, and advanced critical care practitioners
The clinical cases were categorized before the study as:
• Clear ICU admission
• Clear rejection
• Clinically ambiguous or borderline
For each case, participants rated the likelihood of ICU admission, their level of stress, and whether they would admit the patient if resources were unlimited. They also selected the primary reason for declining admission.
The results demonstrated substantial variability in ICU admission decisions. Across all vignettes, the median likelihood of admission was 5 on a 10-point scale, with a wide interquartile range of 6. This indicated that clinicians frequently reached very different conclusions when reviewing the same clinical information.
The greatest disagreement occurred in clinically ambiguous cases. These borderline cases also generated the highest stress levels, emphasizing the cognitive and emotional difficulty of determining whether a critically ill patient is likely to benefit from intensive care.
Senior decision-makers and other clinical staff showed similar overall admission patterns. However, decision-makers reported significantly less stress than non-decision-makers:
Decision-makers: median stress score of 4
Non-decision-makers: median stress score of 5
Although senior physicians carried final responsibility for the admission decision, nurses, junior doctors, and other clinical professionals reported greater stress. The authors suggested that this may reflect moral distress, disagreement with the ultimate decision, or limited ability to influence the outcome.
Clinicians whose primary specialty was intensive care medicine also reported lower stress than clinicians from other specialties.
One of the study’s most unexpected findings was that participants were less likely to admit patients when asked to imagine that healthcare resources were unlimited. The median admission likelihood fell from 5 under current conditions to 3 with unlimited resources.
The authors proposed that clinicians may have imagined a better overall healthcare system with stronger high-dependency units, better ward staffing, and enhanced monitoring outside the ICU. Some patients currently admitted to the ICU may therefore be admitted because safer alternatives are unavailable rather than because they absolutely require intensive care.
The most common reason for refusing ICU admission was futility, cited in 32.4% of responses. Other frequent reasons included:
• Multiple serious medical conditions
• High anticipated six-month mortality
• The patient being too well for intensive care
The frequent use of “futility” was concerning because the term is subjective and lacks a universally accepted clinical definition. Different clinicians may interpret the same prognosis very differently, potentially affecting whether an individual patient receives access to intensive care.
What You Should Know
ICU admission decisions vary substantially, even among experienced intensive care physicians reviewing identical clinical cases.
Borderline or ambiguous cases generate the greatest disagreement and the highest levels of clinician stress.
Senior ICU physicians experience less decisional stress than nurses, junior physicians, and other clinical staff.
A patient’s access to intensive care may be influenced by the individual clinician’s experience, risk tolerance, personal judgment, and interpretation of likely benefit.
The lower admission likelihood under unlimited-resource conditions suggests that some current ICU admissions may compensate for inadequate intermediate-care or ward-level resources.
“Futility” was the most frequently cited reason for denying ICU admission, despite being a subjective and value-laden concept.
The findings support the development of structured decision-support tools, clearer admission frameworks, better interdisciplinary communication, and improved discussions with patients and families regarding goals of care.
Artificial intelligence and large language models may eventually help summarize complex clinical information and reduce cognitive overload, but they should support rather than replace clinician judgment.
Important limitations include the regional UK setting, relatively small sample, reliance on hypothetical scenarios, and the absence of patient and family preferences from the vignettes.
Thank you to Cureus for allowing us to summarize this article.