Table 3a.

MORAL balance analysis of the clinical scenario. Establishing the facts and outcomes of relevance

Make sure of the facts
What is the diagnosis?	Is it aneurysmal or hypertensive? (Early prognosis in aneurysmal bleeds is known to be more difficult.) Has there been associated trauma? Has there been a seizure or other confounding factor to contribute to the low GCS score? Are/were anaesthetic or sedative agents used?
What is the prognosis? How certain are we?	Very likely fatal outcome, with almost certain significant functional deficit if survives.
What are the interventions being considered?	(i) Maintenance of airway (tracheal tube), ventilation, and probably cardiovascular support (including invasive monitoring) for period of observation, as per recent professional guidance18 (ii) End-of-life planning
Is it the last bed?	Are there patients that could potentially be stepped down/transferred out? Can an additional space be staffed in theatre recovery?
Outcomes of relevance to the agents
Patient	Safety in diagnosis and prognosis; best possible chance to recover; distress: prolongation of death and interventions; limit emotional harms to family; end-of-life wishes (organ donation?)
Family	All of the above; grief: positive legacy/lack of regrets; time to come to terms with events and for family to attend (distant son)
Staff	All of the above; moral distress at providing potentially distressing futile therapy; emotional fatigue; time to communicate empathically and sensitively with family; admission of repeated ‘palliative’ admissions likely to increase unit standardised mortality ratio
Other patients/wider NHS	ICU expensive and limited availability resource—marginal cost to next potential patient; if organ donation occurs: recipient lives saved/transformed and NHS resources saved