Priority setting in a hospital critical care unit: Qualitative case
study*
Jens Mielke, DA, MHSC, MRCP; Douglas K. Martin, PhD; Peter A. Singer, MD, MPH, FRCPC
Objective: To describe priority setting for admissions in a
hospital critical care unit and to evaluate it using the ethical
framework of “accountability for reasonableness.”
Design: Qualitative case study and evaluation using the ethical
framework of accountability for reasonableness.
Setting: A medical/surgical intensive care unit in a large urban
university-affiliated teaching hospital in Toronto, Canada.
Participants: Critical care unit staff including medical directors, nurses, residents, referring physicians, and members of a
hospital committee that formulated an admissions policy.
Interventions: Modified thematic analysis of documents, interviews with participants, and direct observation of critical care
unit rounds. Evaluation using the four conditions of Daniels and
Sabin’s accountability for reasonableness: relevance, publicity,
appeals/revisions, and enforcement.
Measurements and Main Results: We examined key features
and participants’ views about the priority setting process. Decisions to admit patients involve a complex cluster of reasons. Both
medical and nonmedical reasons are used, although the nonmed-
C
ritical care beds are usually in
greater demand than can be
met—sometimes leading to
tragic consequences (1, 2).
Prioritizing which patients should be admitted is a serious and ongoing challenge
for every critical care unit. Moreover, priority setting in critical care is important
because intensive care is expensive (3). A
few studies have quantitatively evaluated
issues of critical care access and the morbidity and mortality consequences of intensive care unit (ICU) bed shortages (4 –
*See also p. 2809.
University of Zimbabwe Medical School (JM); Collaborative Program in Bioethics (DKM) and Department
of Health Policy, Management and Evaluation and the
Joint Centre for Bioethics, University of Toronto; Joint
Centre for Bioethics (PAS), University of Toronto.
Supported, in part, by grant 6606-06-1999/
2590074 from the Canadian Institute of Health Research, by an Ontario Ministry of Health and LongTerm Care Career Scientist award (DKM), and by a
Canadian Institutes of Health Research Investigator
award (PAS).
Copyright © 2003 by Lippincott Williams & Wilkins
DOI: 10.1097/01.CCM.0000098440.74735.DE
2764
ical reasons are less well documented and understood. Medical
directors, who are the chief decision makers, differ in their
reasoning. Admitting decisions and reasons are usually explained
to referring staff but seldom to patients and families, and nonmedical reasons are seldom surfaced. A hospital critical care
admissions policy exists but is not used and is not known to all
stakeholders. A formal appeals/revisions process exists, but appeals usually involve informal negotiations. The existence of
priority programs in the hospital (e.g., transplantation) adds complexity and heightens disagreement by stakeholders.
Conclusion: We have described and evaluated admissions decision making in a hospital’s critical care unit. The key lesson of
our study is not only the specific findings obtained here but
also how combining a case study approach with the ethical
framework of “accountability for reasonableness” can be used
to identify good practices and opportunities for improving the
fairness of priority setting in intensive care. (Crit Care Med
2003; 31:2764 –2768)
KEY WORDS: priority setting; admissions; critical care
6), including effects of discharges at
night (7). The American Thoracic Society’s Bioethics Task Force developed a
statement “Fair Allocation of Intensive
Care Unit Resources” (8), and the Society
of Critical Care Medicine published
guidelines for ICU admission, discharge,
and triage (9). Both guidelines describe
substantive criteria (e.g., potential benefit) that might be used in setting admissions priorities. But how are priority setting decisions in an ICU actually made?
Zussman (10) conducted an in-depth
qualitative study of two critical care units
over 5 yrs and concluded that, “It is all
very well and good to develop [priority
setting criteria]. But such criteria matter
not at all if they are ignored, for what is
left out of the predictive models—as well
as of the ethical reflections on triage—is
any sense of the socially structured pressures operating on physicians, . . .the social structures that generate advocacy
and disinterest, that generate indifference to some patients and commitments
to others.” Strosberg and Teres (11) explored “gatekeeping” in critical care units
using illustrative case studies. They describe most gatekeeping decisions in critical care units as being ad hoc and political and not conforming to clear rules.
These studies are helpful but limited because the authors did not use an explicit
ethical framework to evaluate actual priority setting in critical care.
Daniels and Sabin (12) developed an
ethical framework for priority setting
called “accountability for reasonableness.” Because it is very difficult for decision makers to reach agreement on
substantive criteria for fair priority setting, accountability for reasonableness is
an explicit framework for determining
what is a fair priority-setting process. Developed in the context of private healthcare organizations in the United States
(13), it is also relevant in public healthcare organizations in Canada and elsewhere (14, 15). Accountability for reasonableness has been used to evaluate
priority setting at the level of health systems; for example, Ham (16, 17) examined “contested decisions” in the UK National Health Service, and Martin and
Crit Care Med 2003 Vol. 31, No. 12
Singer (18) examined priority setting for
health technologies in Canada. However,
to our knowledge, this promising framework has not yet been applied to admission decisions in critical care.
The purpose of this study is to describe priority setting for admissions in a
hospital critical care unit and evaluate it
using accountability for reasonableness.
METHODS
pital guidelines for admission to the MSICU,
minutes of the guideline committee meetings). The second source was semistructured
interviews with 20 key informants, using an
interview guide based on previous prioritysetting case studies but modified according to
emerging findings (available on request); all
interviews were audiotaped and transcribed
(Table 2 describes the interview participants).
The third source was direct observation of
morning rounds and other discussions in the
MSICU by one of the investigators (JM)—a
total of 18 hrs.
Design
This was a qualitative case study. A case
study is “an empirical inquiry that investigates
a contemporary phenomenon within its reallife context” (19). This method is appropriate
for this research because priority setting in
critical care units is complex and contextdependent and involves social processes.
Setting
The setting for this study was the medical
and surgical ICU (MSICU) of a large urban
university-affiliated hospital. It is a 16-bed
closed unit, staffed by critical care specialists.
Other critical care units in the hospital (cardiovascular and coronary care units) were not
examined. In 1998, hospital management recognized that the institution could no longer
admit all patients who presented for admission
to the MSICU, and so MSICU admission guidelines were developed. These guidelines included the creation of priority levels favoring
in-hospital patients and those in priority programs (Table 1).
Sampling
The study was carried out between November 2001 and March 2002. Theoretical sampling was used. This technique is commonly
used in qualitative research and uses prior
knowledge of the setting to focus on those
documents, individuals, and observational settings that may provide information relevant to
the emerging findings.
Data Collection
Three primary data sources were used. The
first source was key documents (e.g., the hos-
Data Analysis
Although this was not a grounded theory
study, we adapted grounded theory analytic
techniques because they are specifically designed for analyzing complex social processes
(such as priority-setting processes) (20, 21).
First, using modified open coding, we examined the data and identified components of the
priority-setting process (e.g., “medical criteria” or “negotiation”). Then, using modified
axial coding, we organized these components
under overarching themes. Because this study
was guided by an explicit conceptual framework, the themes were the four conditions of
accountability for reasonableness (described
subsequently).
We addressed the validity of our findings in
five ways (22). First, we “triangulated” data
from three different sources (documents, interviews, and observations) to maximize comprehensiveness and diversity (23). Second, two
primary researchers coded the raw data and
agreed on the coding list. Third, members of
an independent interdisciplinary research
group, consisting of a philosopher, nurse, hospital administrator, and bioethicist, enhanced
the “reflexivity” in the analysis by participating in the data analysis. Thus, the role of prior
assumptions and experience, which can influence any inquiry, were acknowledged and examined. Fourth, all research activities were
rigorously documented to permit a critical
appraisal of the methods (24). Fifth, a draft of
the findings was distributed to a subgroup of
six participants, and comments were invited as
a “member check.” The participants verified
the accuracy of the report and the reasonableness of the findings.
The Conceptual Framework:
Accountability for
Reasonableness
Daniels and Sabin (12, 25) developed an
ethical framework for legitimate and fair priority setting called accountability for reasonableness. A goal of priority setting is justice.
However, because no societal consensus exists
regarding substantive principles of justice, a
key goal is procedural justice—that is, a legitimate and fair process (26, 27). According to
accountability for reasonableness, an institution’s priority-setting decisions may be considered legitimate and fair if they satisfy four
conditions: relevance, publicity, appeals/
revisions, and enforcement— described in Table 3.
Research Ethics
Approval for this study was obtained from
the Committee on Use of Human Subjects of
the University of Toronto and the hospital’s
research ethics board. Written informed consent was obtained from each individual before
being interviewed. All raw data were protected
as confidential and were available only to the
research team. No individual participants were
identified.
RESULTS
The results have been organized according to the four conditions of accountability for reasonableness (relevance, publicity, revisions, enforcement),
and key points are illustrated with verbatim quotes from participants.
Relevance
Decisions to admit patients to the critical care unit involve a complex cluster of
reasons. Multiple reasons, which participants described as medical or nonmedical, combined in particular ways in each
particular case. The participants in the
decision-making process are the ICU physicians (staff physicians, also called medical directors) and also fellows and residents. A wider range of participants were
involved in developing the admissions
Table 1. Hospital Guidelines for Admission to the Medical Surgical Intensive Care Unit (Excerpt)
Priority 1 (not in order of priority)
Priority 2
Crit Care Med 2003 Vol. 31, No. 12
In-house medical and surgical emergencies
Critically ill patients in the emergency departments
Patients considered to be in a priority program, specifically neurosciences, transplantation, oncology,
cardiovascular diseases, and the patient ambulatory care program
Patients referred from another institution who require urgent management only available at, or specifically
suited to, the expertise offered at the hospital intensive care units
All other patients (the medical director of the unit may decide to upgrade the status of a particular patient)
2765
policy including three members of the
hospital’s Community Advisory Committee, physicians, administrators, legal
counsel, and bioethicists.
Both the ICU physicians and those
who refer to them agree that the patients
who should be admitted to the critical
care unit are those who require the specialized services of the unit and will benefit from them—referred to as medical
reasons: “That’s because of respiratory
failure and the need for mechanical ventilation. And then I suppose the second
most common reason would be, ah, hypotension and the need for intravenous,
ah, inotropic support.” In addition, nonmedical reasons regarding admissions decisions were cited, including the following:
●
●
●
Availability of a bed and nursing staff:
“If we think that the patient would
benefit from coming here the key decision, the key, um, um, factor would
be the availability of a bed and a nurse.
Predominantly a nurse.”
Family pressure: “I think, she [the patient] came because the seed had been
planted with the family.” “There you
have the family, all three of which are
crying and saying: ‘Save her! Save
her!’ You know, it would be a lot more
difficult to just say: ‘Okay, we’ve done
all this in the Emergency Room. We’re
going to just stop now.’”
Hospital policy: The Guidelines for Ad-
mission to the MSICU state priorities.
However, clinicians’ understanding
and application of these priorities varied, most notably by placing transplant
patients above other priority programs
contrary to the policy: “If there were
two patients who needed to come into
the ICU and one of them was a transplant patient and the other one was
something else, the transplant patient
would take priority.”
However, medical personnel felt some
concern about basing priorities on hospital programs: “If you have any questions
in your mind about that then I think the
process is not entirely fair because there
is some priority given to the transplant
or the neurosurgery case. You know,
some of us feel, I think, that there is
some unfairness there.”
The perception held by many non-ICU
hospital staff is that the ICU physicians
use well-defined medical criteria for their
decisions: “And they have their set of
clinical criteria which, you know, is like
the law. It’s very black and white and it’s
very easy to deal with. So, you know, if
this patient is on a ventilator and, you
know, blah, blah, blah. . .this has got to
be a patient who’s ready for the ICU and
they will admit the patient. And if there’s
actually something they can do for the
patient in the ICU, they will admit the
patient. These criteria are hard and
Table 2. Study Participants (n ⫽ 20)
Medical Personnel
Nursing Personnel
Others
ICU directors (staff physicians, intensivists), 5
ICU fellows, 1
ICU residents, 2
Referring physicians, 4
Transplant surgeon, 1
Vascular surgeon, 1
Internal medicine, 2
Total, 12
ICU nurse manager, 1
ICU nurse, 2
Committee members, 3
ICU administrator, 1
Patient relations rep, 1
Total, 5
Total, 3
ICU, intensive care unit.
they’re well-defined and they’re based on
standard of practice.”
However, ICU physicians themselves
perceive these decisions to be a negotiated process: “The admission of patients
to the unit is a negotiated process. Most
of the time it functions. . .implicitly.”
Physicians who make the admission
decisions, and others who observe them,
agreed that there are differences in the
way they are made: “I think you could
show that case scenario to some intensivists and they would say: ‘Sure, I’d
bring that patient.’ Others would say, ‘I
think they’ll be fine’ [i.e., do not need
admission].” “Amongst our directors. . .you can see very different people
who get admitted to the ICU.”
The primary decision makers, the
medical directors, are aware of differences among themselves regarding admission decisions but accept this as inevitable, given differences in experience,
attitudes, and familiarity with the hospital. None would say any of the others was
wrong in making a decision one way or
the other, but they also would not usually
consult a colleague in making even quite
difficult decisions. “The differences are
coloured a little bit by your. . .your level
of comfort, um, and your knowledge of
the place where you work.”
Some referring physicians have great
concern with the variability of admission
decisions: “When I phone up and I say I’ve
got a call from Hospital X that they have a
ruptured aneurysm. . .and they say ‘Well,
we do not have a nurse to look after the
patient.’ But if they get a call a half-hour
later that there’s a liver, they will. . .they
will obviously go to the end of the earth to
do the liver. But the aortic aneurysm has
less priority, even though you’ll die of your
aortic aneurysm.. . .Our perception is that,
be it true or not, that they will go the extra
mile for a lung transplant or a liver or a
kidney/pancreas. And I can understand
that, but it’s sort of basically saying, okay,
Table 3. Four Conditions of Accountability for Reasonableness
Condition
Relevance
Publicity
Appeals/revisions
Enforcement
2766
Description
Priority-setting decisions must rest on reasons (including evidence and principles) that fair-minded participants can agree are
relevant to meeting context-specific goals under resource constraints. Fair-minded participants are stakeholders who are
disposed to decision making according to rules of mutual cooperation and can involve managers, clinicians, patients, and
consumers in general.
Priority-setting decisions and their rationales must be publicly accessible.
The priority-setting process must include a mechanism for challenge and dispute resolution regarding priority-setting
decisions, including the opportunity for revising decisions in light of further evidence or principles.
There must be voluntary or public regulation of the process to ensure that the first three conditions are met.
Crit Care Med 2003 Vol. 31, No. 12
well, you’re. . .you’re at the bottom of the
barrel, so pick another apple.”
Publicity
Regarding individual patients, ICU
physicians communicate their decisions
and reasons primarily to the referring
physicians. Occasionally, but not always,
the family is told. “The ICU resident
would have come down, done the consult
and said to the ward team, ‘No.’ Or they
may have said to the family, en passant,
‘Sorry, no,’ and then disappeared and
then the family would have said, ‘Why?’”
In regard to the publicity of the admissions policy, the minutes of the committee formed to create the guidelines
portray an inclusive, transparent process.
The minutes state an intention to circulate the guidelines widely, including to all
doctors and nurses in the hospital. At the
time of our study, there was little awareness of written guidelines in the hospital:
“I do not know if there is a policy. It
seems reasonable that there would be,
but I have never come (across) it in my
one month of ICU.”
Healthcare staff were unanimous in
suggesting that public education about
intensive care would assist the admissions process: “The average Ontarian has
absolutely no clue how the system works.
They think they do but they have absolutely no clue. Intelligent, empowered,
well-placed people come into the hospital
expecting. . .what they see on television,
perhaps, you know. And they are stunned
that it doesn’t work that way.”
Appeals/Revisions
The Guidelines for Admission to the
MSICU state: “Any patient or relative who
is denied admission to the Unit, or any
physician, may challenge the decision. In
this circumstance, the individual is entitled to a full explanation of the guidelines
and their implementation by a representative of Patient Relations.” However, formal appeals are rare. Differences of opinion between hospital staff are negotiated
informally: “We could in theory get into
some conflict where the referring physician would, you know, really feel
strongly. There is a mechanism of appeal
available for that. There is a second intensive care person who could be called
in and review the case and help make
that decision.”
Differences between hospital staff and
patients or families usually are addressed
Crit Care Med 2003 Vol. 31, No. 12
informally. Occasionally, the Patient Relations Department intervenes using
techniques of conflict resolution to negotiate outcomes. Communication issues
are commonly at the root of the appeal:
“So it’s perceived to be bad care or a bad
attitude or lack of communication, but
really it’s a communication botch-up.”
Enforcement
There was no indication of administration support for enforcing the conditions
of accountability for reasonableness or
equivalent concepts. In addition, during
the period of observation and in the interviews, we detected no formal effort to
enforce the admissions guidelines.
DISCUSSION
This is the first study to describe actual
admission decision making in a critical
care unit and evaluate it using accountability for reasonableness. Previously, accountability for reasonableness has been used to
evaluate priority setting at the level of
health systems (15, 16, 28) To date, it has
not been used to evaluate priority setting
for admissions to critical care units, and so
our study fills this gap in the literature.
Our study demonstrates that it is feasible to describe and evaluate priority setting in critical care units using the methods we described and by doing so to
generate lessons for improving the fairness of the priority setting process. In the
absence of agreement regarding the “correct” set of admission criteria, fairness is
a key priority-setting goal in critical care.
Other critical care units may find the
specific findings of this study helpful;
also, it is likely that they would benefit
from using these methods to improve priority setting in their own context.
Lessons
Relevance. Despite perceptions to the
contrary on the part of other hospital
staff, intensivists consider both medical
and nonmedical factors when making admissions decisions. The existing hospital
admissions policy is partially understood
and used sometimes (e.g., by elevating
the status of transplant admissions) but
not at other times (e.g., emergency department and oncology patients have the
same standing as transplant patients according to the guidelines but are not prioritized in the same way). Many actual
admission decisions conflict with the pol-
icy either because the policy is not known
or because the guidelines do not fit the
intensivists’ understanding of the hospital’s priorities. At this hospital, the perceived primacy of the transplant program
over other priority programs, for example, would lead to intensivists bending
over backward for transplant patients in
favor of patients from other equally entitled programs. No guidance is provided
by the policy when two or more similarly
needy patients from priority programs
present simultaneously. Moreover, different intensivists make different independent judgments. Consequently, in many
cases, whether a patient is admitted to
the ICU seems to depend on who is making the decision that day. These findings
correspond to previous studies by Zussman (10) and Strosberg and Teres (11).
Intensivists’ independence probably has
its roots in a sense of autonomy that
intensivists have about professional decisions, and it is what is expected of them
when trained as intensivists. How to reshape their decision making so that it is
more participatory and more consistent
between intensivists is an important
question that is beyond the scope of this
article.
Publicity. The hospital’s admissions
policy is not widely known within the
hospital and not known at all outside the
hospital. Decisions and their reasons are
only occasionally discussed with patients
or their families. There is clearly room
for greater transparency or explanation
regarding reasons for admissions, in both
a specific (explanations to families) and a
general sense (widespread awareness of
the guidelines).
Appeals/Revisions. A formal avenue of
appeal/revision does exist but is rarely
used. Informal discussions are most often
used. Clinicians make different decisions
about who should be admitted to the
MSICU but do not have opportunities to
debate their reasons.
Enforcement. Ideas for enforcement
were included with the original guidelines document, including provision for a
mandatory review 6 months after adoption of the guidelines. This has not, however, materialized, nor is there monitoring of admissions decisions.
Accountability for reasonableness provides an explicit ethical framework that
can be used to identify good practices and
recommendations for improvement. In
this case study, we identified two good
practices: a) Priority setting decisions are
made according to criteria that many
2767
T
he key lesson of
our study is not
only the specific
findings obtained here but
also how combining a case
study approach with the ethical framework of accountability for reasonableness
can be used to identify good
practices and opportunities
for improving the fairness of
priority setting in critical
care.
agree are relevant to the context of a
hospital ICU; and b) there is a formal
appeals/revisions mechanism for addressing challenges to priority-setting reasoning. Recommendations for improving
priority setting that we identified in this
case study include the following: a) There
should be regular discussion of admission
decisions at meetings of the entire ICU
team to increase understanding of relevant rationales and how they should be
applied; b) decisions and their reasons
should be communicated to the patient
and/or family (depending on the patient’s
status and the family’s involvement); c)
the hospital should provide a forum for
reviewing the ICU admissions guidelines
and increase efforts to enhance its staff’s
understanding of the guidelines (e.g., via
grand rounds, unit rounds, and the hospital’s intranet) and to increase public
understanding of decision making in its
intensive care units (e.g., via the media,
the hospital’s Web site, and other public
forums); and d) the hospital should formally monitor priority setting in the ICU
to ensure that the decisions are made
fairly (i.e., according to the conditions of
accountability for reasonableness).
Limitations
The main limitation of our study is
that it was conducted in a single intensive
care unit and the results may not be
2768
generalizable. Despite this limitation, our
findings conform to our clinical experience in several units. We anticipate that
staff of other units will recognize their
own processes in our findings. On the
other hand, generalizability is not an objective of qualitative case studies such as
this—the goal is to describe this particular case. The process we have used—to
describe using case study methods and
evaluate using accountability for reasonableness—is generalizable and can be
used by others to identify good practices
and opportunities for improvement in
their own context.
CONCLUSIONS
We have described and evaluated admissions decision making in a hospital’s critical care unit. The key lesson of our study is
not only the specific findings obtained here
but also how combining a case study approach with the ethical framework of accountability for reasonableness can be used
to identify good practices and opportunities
for improving the fairness of priority setting in critical care.
ACKNOWLEDGMENTS
Thank you to Mark Bernstein and Neil
Lazar for valuable assistance in this
project and to Norman Daniels for ongoing help.
REFERENCES
1. Bhinder S: Our reformed health-care system
has fatal price tag. Toronto Star 2000; January 28
2. Gollom M: Fatal rerouting inquest begins:
Teenager died after hospital refused admission. National Post 2000; September 11, p
A20
3. Cook D, Giacomini M: The sound of silence:
Rationing resources for critically ill patients.
Crit Care 1999; 3:R1–R3
4. Parmanum J, Field D, Rennie J, et al: National census of availability of neonatal intensive care. British Association for Perinatal
Medicine. BMJ 2000; 321:727–729
5. Metcalfe MA, Sloggett A, McPherson K: Mortality among appropriately referred patients
refused admission to intensive-care units.
Lancet 1997; 350:7–11
6. Sprung CL, Geber D, Eidelman LA, et al:
Evaluation of triage decisions for intensive
care admission. Crit Care Med 1999; 27:
1073–1079
7. Goldfrad C, Rowan K: Consequences of discharges from intensive care at night. Lancet
2000; 355:1138 –1142
8. American Thoracic Society Bioethics Task
Force. Fair Allocation of Intensive Care Unit
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Resources. Am J Respir Crit Care Med 1997;
156:1282–1301
Society of Critical Care Medicine Ethics
Committee. Consensus Statement on the
Triage of Critically Ill Patients. JAMA 1994;
271:1200 –1203
Zussman R: Intensive Care. Chicago, University of Chicago Press, 1992
Strosberg MA, Teres D: Gatekeeping in the
Intensive Care Unit. Chicago, Health Administration Press, 1997
Daniels N, Sabin JE: Setting Limits Fairly:
Can We Learn to Share Medical Resources?
Oxford, UK, Oxford University Press, 2002
Daniels N, Sabin JE: The ethics of accountability in managed care reform. Health Affairs 1998; 17:50 – 64
Martin DK, Giacomini M, Singer PA: Fairness, accountability for reasonableness, and
the views of priority setting decision-makers.
Health Policy 2002; 61:279 –290
Ham C, Roberts G (Eds): Reasonable Rationing: International Experience of Priority Setting in Health Care, London, UK, Open University Press, in press
Ham C: Tragic choices in health care: Lessons from the Child B case. BMJ 1999; 319:
1258 –1261
Ham C, McIver S: Contested Decisions: Priority Setting in the NHS. London, UK, King’s
Fund Publishing, 2000
Martin DK, Singer PA: Priority setting for
health technologies in Canada. In: Reasonable Rationing: International Experience of
Priority Setting in Health Care. Ham C, Roberts G (Eds). London, UK, Open University
Press, in press
Yin RK: Case Study Research: Design and
Methods. Thousand Oaks, CA, Sage, 1994
Strauss A, Corbin J: Basics of Qualitative
Research: Techniques and Procedures of Developing Grounded Theory. Thousand Oaks,
CA, Sage, 1998
Strauss A, Corbin J: Grounded theory methodology: An overview. In: Handbook of Qualitative Research. Denzin NK, Lincoln YS
(Eds). Thousand Oaks, CA, Sage, 1994
Altheide DL, Johnson JM: Criteria for assessing interpretive validity in qualitative research. In: Handbook of Qualitative Research. Denzin NK, Lincoln YS (Eds).
Thousand Oaks, CA, Sage, 1994, pp 485– 499
Mays N, Pope C: Qualitative research in
health care: Assessing quality in qualitative
research. BMJ 2000; 320:50 –52
Mays N, Pope C: Rigour and qualitative research. BMJ 1995; 311:109 –112
Daniels N: Accountability for reasonableness.
BMJ 2000; 321:1300 –1301
Daniels N: Four unsolved rationing problems: A challenge. Hastings Center Report
1994; 24:27–29
Daniels N: Justice, health, and health care.
Am J Bioethics 2001; 1:2–16
Ham C, McIver S: Contested Decisions: Priority Setting in the NHS. London, UK, King’s
Fund Publishing, 2000
Crit Care Med 2003 Vol. 31, No. 12