{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T05:10:08Z","timestamp":1788844208435,"version":"build-2803163510"},"reference-count":70,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2026,9,5]],"date-time":"2026-09-05T00:00:00Z","timestamp":1788566400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004587","name":"Instituto de Salud Carlos III","doi-asserted-by":"crossref","award":["JR22\/00004"],"award-info":[{"award-number":["JR22\/00004"]}],"id":[{"id":"10.13039\/501100004587","id-type":"DOI","asserted-by":"crossref"}]},{"award":["JR22\/00004"],"award-info":[{"award-number":["JR22\/00004"]}],"id":[{"id":"https:\/\/ror.org\/00ca2c886","id-type":"ROR","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000780","name":"European Union","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100000780","id-type":"DOI","asserted-by":"crossref"}]},{"id":[{"id":"https:\/\/ror.org\/019w4f821","id-type":"ROR","asserted-by":"publisher"}]},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red de Enfermedades Cardiovasculares"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background\/Objectives: Contemporary cardiovascular critical care is increasingly shaped by advanced technologies, prognostic uncertainty, and time-sensitive decisions regarding mechanical circulatory support, treatment limitation, device management, family communication, and end-of-life care. Although established ethical principles provide essential normative guidance, their integration into routine bedside workflows remains challenging. This review examines the principal ethical tensions arising in the Cardiovascular Intensive Care Unit (CICU) and proposes a practical framework for real-time ethical decision-making. Methods: A narrative review of the contemporary literature was performed using major biomedical databases together with international guidelines, scientific statements, consensus documents, and relevant ethics literature to identify the principal ethical challenges encountered in contemporary cardiovascular intensive care and to develop an implementation-oriented framework for integrating ethical reasoning into routine clinical workflows. Results: Ethical challenges in the CICU frequently arise during transitions between therapeutic escalation, reassessment, limitation, withdrawal, and comfort-focused care. These decisions are influenced not only by clinical prognosis but also by organisational culture, multidisciplinary dynamics, patient preferences, communication, and structural inequities. We propose Operational Ethics as an implementation framework that embeds ethical reflection into routine clinical workflows through continuous reassessment of therapeutic goals, proportionality, prognosis, patient values, and multidisciplinary deliberation. Practical strategies include ethical pause points, time-limited trials, structured communication pathways, anticipatory device discussions, regular goals-of-care reassessment, and institutional support for clinicians experiencing moral distress. Conclusions: Operational Ethics complements established bioethical principles by translating them into practical bedside processes adapted to the temporal and organisational realities of cardiovascular critical care. Its integration into routine CICU practice may support more consistent, equitable, and patient-centred decisions while ensuring that technological possibilities remain aligned with meaningful clinical goals.<\/jats:p>","DOI":"10.3390\/jcm15176885","type":"journal-article","created":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T12:12:25Z","timestamp":1788783145000},"page":"6885","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Operational Ethics in the Cardiovascular Intensive Care Unit: A Practical Framework for Ethical Decision-Making"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7914-9788","authenticated-orcid":false,"given":"Lourdes","family":"Vicent","sequence":"first","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Instituto de Investigaci\u00f3n Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1038-9710","authenticated-orcid":false,"given":"Rafael","family":"Salguero-Bodes","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Instituto de Investigaci\u00f3n Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"},{"name":"Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-2262-1222","authenticated-orcid":false,"given":"Pablo","family":"R. Alonso","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Instituto de Investigaci\u00f3n Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elena","family":"Puerto","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Instituto de Investigaci\u00f3n Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"},{"name":"Comit\u00e9 de \u00c9tica de la Investigaci\u00f3n con Medicamentos, Hospital 12 de Octubre, 28041 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5101-2832","authenticated-orcid":false,"given":"Carlos","family":"Diaz-Arocutipa","sequence":"additional","affiliation":[{"name":"Unidad de Revisiones Sistem\u00e1ticas y Meta-An\u00e1lisis (URSIGET), Vicerrectorado de Investigaci\u00f3n, Universidad San Ignacio de Loyola, Lima 15024, Peru"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fernando","family":"Arribas Ynsaurriaga","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Instituto de Investigaci\u00f3n Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"},{"name":"Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberto","family":"Mart\u00edn-Asenjo","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain"},{"name":"Instituto de Investigaci\u00f3n Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain"},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain"},{"name":"Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,5]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"24","DOI":"10.14797\/mdcvj.1092","article-title":"Cardiac Critical Care: The Evolution of a Novel Subspecialty","volume":"18","author":"Gage","year":"2022","journal-title":"Methodist. Debakey Cardiovasc. J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1186\/s40560-017-0271-7","article-title":"Evolved Role of the Cardiovascular Intensive Care Unit (CICU)","volume":"5","author":"Kasaoka","year":"2017","journal-title":"J. Intensive Care"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"596","DOI":"10.1016\/j.cardfail.2024.01.011","article-title":"The Future of Durable Mechanical Circulatory Support: Emerging Technological Innovations and Considerations to Enable Evolution of the Field","volume":"30","author":"Dual","year":"2024","journal-title":"J. Card. Fail."},{"key":"ref_4","first-page":"915197","article-title":"The Ethics of Rationing of Critical Care Services: Should Technology Assessment Play a Role?","volume":"2009","author":"Bloomfield","year":"2009","journal-title":"Anesthesiol. Res. Pract."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"175","DOI":"10.4046\/trd.2015.78.3.175","article-title":"Ethics in the Intensive Care Unit","volume":"78","author":"Moon","year":"2015","journal-title":"Tuberc. Respir. Dis."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Liu, Y., Ying, L., Zhang, Y., and Jin, J. (2023). The Experiences of Intensive Care Nurses Coping with Ethical Conflict: A Qualitative Descriptive Study. BMC Nurs., 22.","DOI":"10.1186\/s12912-023-01612-2"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e87","DOI":"10.1136\/medethics-2020-106672","article-title":"Ethical Conflicts during the Process of Deciding about ICU Admission: An Empirically Driven Ethical Analysis","volume":"47","author":"Svantesson","year":"2021","journal-title":"J. Med. Ethics"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Oerlemans, A.J.M., van Sluisveld, N., van Leeuwen, E.S.J., Wollersheim, H., Dekkers, W.J.M., and Zegers, M. (2015). Ethical Problems in Intensive Care Unit Admission and Discharge Decisions: A Qualitative Study among Physicians and Nurses in the Netherlands. BMC Med. Ethics, 16.","DOI":"10.1186\/s12910-015-0001-4"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"40","DOI":"10.7861\/fhj.2020-0233","article-title":"Implicit Bias in Healthcare: Clinical Practice, Research and Decision Making","volume":"8","author":"Gopal","year":"2021","journal-title":"Future Healthc. J."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.ejim.2022.08.021","article-title":"Angiographic and Clinical Outcome of SARS-CoV-2 Positive Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Angioplasty: A Collaborative, Individual Patient Data Meta-Analysis of Six Registry-Based Studies","volume":"105","author":"Silverio","year":"2022","journal-title":"Eur. J. Intern. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1136","DOI":"10.1111\/jgs.16537","article-title":"AGS Position Statement: Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond","volume":"68","author":"Farrell","year":"2020","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Bouchlarhem, A., Bazid, Z., Ismaili, N., and El Ouafi, N. (2023). Cardiac Intensive Care Unit: Where We Are in 2023. Front. Cardiovasc. Med., 10.","DOI":"10.3389\/fcvm.2023.1201414"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1016\/j.mayocp.2018.09.020","article-title":"Decisions to Withdraw Extracorporeal Membrane Oxygenation Support: Patient Characteristics and Ethical Considerations","volume":"94","author":"DeMartino","year":"2019","journal-title":"Mayo Clin. Proc."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1016\/j.anclin.2024.02.008","article-title":"End-of-Life Care in the Intensive Care Unit and Ethics of Withholding\/Withdrawal of Life-Sustaining Treatments","volume":"42","author":"Cortegiani","year":"2024","journal-title":"Anesthesiol. Clin."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e014355","DOI":"10.1161\/JAHA.119.014355","article-title":"Different Lenses for the Same Story: Examining How Implicit Bias Can Lead Us to Different Clinical Decisions for the \u201cSame\u201d Patient","volume":"8","author":"Shirey","year":"2019","journal-title":"J. Am. Heart Assoc."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"90176","DOI":"10.5492\/wjccm.v13.i1.90176","article-title":"21st Century Critical Care Medicine: An Overview","volume":"13","author":"Padte","year":"2024","journal-title":"World J. Crit. Care Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"156","DOI":"10.3121\/cmr.2015.1289","article-title":"Understanding Decision Making in Critical Care","volume":"13","author":"Lighthall","year":"2015","journal-title":"Clin. Med. Res."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1186\/s13054-022-04094-x","article-title":"Improving the Intensive Care Experience from the Perspectives of Different Stakeholders","volume":"26","author":"Latour","year":"2022","journal-title":"Crit. Care"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"112","DOI":"10.21037\/atm.2017.01.38","article-title":"Extra Corporeal Membrane Oxygenation Support: Ethical Dilemmas","volume":"5","author":"Makdisi","year":"2017","journal-title":"Ann. Transl. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"103430","DOI":"10.1016\/j.iccn.2023.103430","article-title":"Clinical Decision-Making in the Intensive Care Unit: A Concept Analysis","volume":"77","author":"Yee","year":"2023","journal-title":"Intensive Crit. Care Nurs."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1177\/09697330251385024","article-title":"Ethical Concerns of AI in Healthcare: A Systematic Review of Qualitative Studies","volume":"33","author":"Hou","year":"2026","journal-title":"Nurs. Ethics"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e001389","DOI":"10.1136\/tsaco-2024-001389","article-title":"Ethics in Disaster, Mass Casualty Care, and Critical Care","volume":"9","author":"Egodage","year":"2024","journal-title":"Trauma. Surg. Acute Care Open"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"141","DOI":"10.2147\/AMEP.S59022","article-title":"Factors Associated with Clinical Inertia: An Integrative Review","volume":"5","author":"Aujoulat","year":"2014","journal-title":"Adv. Med. Educ. Pract."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1086\/JCE2022331013","article-title":"Ethics of Extracorporeal Membrane Oxygenation under Conventional and Crisis Standards of Care","volume":"33","author":"Piscitello","year":"2022","journal-title":"J. Clin. Ethics"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"11","DOI":"10.14797\/mdcj-9-1-11","article-title":"Ethical Dilemmas Surrounding the Use of Ventricular Assist Devices in Supporting Patients with End-Stage Organ Dysfunction","volume":"9","author":"Bruce","year":"2013","journal-title":"Methodist. Debakey Cardiovasc. J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1186\/s12961-016-0152-x","article-title":"A Systematic Review on Current Status of Health Technology Reassessment: Insights for South Korea","volume":"14","author":"Seo","year":"2016","journal-title":"Health Res. Policy Sys."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1513\/AnnalsATS.202310-925ST","article-title":"Defining the Time-Limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report","volume":"21","author":"Kruser","year":"2024","journal-title":"Ann. Am. Thorac. Soc."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"786","DOI":"10.1001\/jamainternmed.2021.1000","article-title":"Evaluation of Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses and Reduction of Nonbeneficial ICU Treatments","volume":"181","author":"Chang","year":"2021","journal-title":"JAMA Intern. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1016\/j.bjae.2018.11.006","article-title":"\u201cMORAL Balance\u201d Decision-Making in Critical Care","volume":"19","author":"Harvey","year":"2019","journal-title":"BJA Educ."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e50","DOI":"10.1161\/CIR.0000000000001076","article-title":"Escalating and De-Escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association","volume":"146","author":"Geller","year":"2022","journal-title":"Circulation"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e069536","DOI":"10.1136\/bmjopen-2022-069536","article-title":"Is the Process of Withdrawal of Life-Sustaining Measures in the Intensive Care Unit Different for Deceased Organ Donors Compared with Other Dying Patients? A Secondary Analysis of Prospectively Collected Data","volume":"13","author":"Shahin","year":"2023","journal-title":"BMJ Open"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1177\/19418744221123194","article-title":"End-Of-Life Care in the Potential Donor after Circulatory Death: A Systematic Review","volume":"13","author":"Cappucci","year":"2023","journal-title":"Neurohospitalist"},{"key":"ref_33","first-page":"190","article-title":"End-of-Life Care in the Cardiac Intensive Care Unit: A Contemporary View from the Critical Care Cardiology Trials Network (CCCTN) Registry","volume":"11","author":"Fagundes","year":"2022","journal-title":"Eur. Heart J. Acute Cardiovasc. Care"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"791","DOI":"10.1007\/s11606-011-1632-x","article-title":"Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them","volume":"26","author":"Yuen","year":"2011","journal-title":"J. Gen. Intern. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"288","DOI":"10.5455\/medarh.2023.77.288-292","article-title":"Do-Not-Resuscitate (DNR) Orders\u2019 Awareness and Perception Among Physicians: A National Survey","volume":"77","author":"Alahmadi","year":"2023","journal-title":"Med. Arch."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1186\/cc3486","article-title":"Withdrawing May Be Preferable to Withholding","volume":"9","author":"Vincent","year":"2005","journal-title":"Crit. Care"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e1075","DOI":"10.1161\/CIR.0000000000001334","article-title":"Palliative and End-of-Life Care During Critical Cardiovascular Illness: A Scientific Statement From the American Heart Association","volume":"151","author":"Bohula","year":"2025","journal-title":"Circulation"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"16","DOI":"10.7812\/TPP\/16-037","article-title":"Use of Improving Palliative Care in the ICU (Intensive Care Unit) Guidelines for a Palliative Care Initiative in an ICU","volume":"21","author":"Mun","year":"2017","journal-title":"Perm. J."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1017\/S1478951511000423","article-title":"Palliative Medicine Consultation Impacts DNR Designation and Length of Stay for Terminal Medical MICU Patients","volume":"9","author":"Lustbader","year":"2011","journal-title":"Palliat. Support. Care"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"110734","DOI":"10.1016\/j.resuscitation.2025.110734","article-title":"European Resuscitation Council Guidelines 2025 Ethics in Resuscitation","volume":"215","author":"Raffay","year":"2025","journal-title":"Resuscitation"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1057\/s41599-022-01206-4","article-title":"Empowered and Embedded: Ethics and Agile Processes","volume":"9","author":"Zuber","year":"2022","journal-title":"Humanit. Soc. Sci. Commun."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"468","DOI":"10.1186\/s13054-023-04758-2","article-title":"The Use of Checklists in the Intensive Care Unit: A Scoping Review","volume":"27","author":"Erikson","year":"2023","journal-title":"Crit. Care"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1161\/CIRCEP.109.848523","article-title":"Should Implantable Cardioverter-Defibrillators and Permanent Pacemakers in Patients with Terminal Illness Be Deactivated? Deactivating Permanent Pacemaker in Patients with Terminalillness. Patient Autonomy Is Paramount","volume":"2","author":"Zellner","year":"2009","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Mugnai, G., Genovese, D., Tomasi, L., Gambaro, A., and Ribichini, F. (2025). The Implantable Cardioverter-Defibrillators at the End of Life: A Double-Edged Sword of a Life-Saving Technology. Trends Cardiovasc. Med.","DOI":"10.1016\/j.tcm.2025.09.005"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"e1716","DOI":"10.1016\/j.hrthm.2026.04.015","article-title":"2026 HRS\/AHA\/APHRS\/EHRA\/IDSA\/LAHRS\/PACES\/STS Expert Consensus Statement Update on Cardiovascular Implantable Electronic Device Lead Management and Extraction","volume":"23","author":"Cha","year":"2026","journal-title":"Heart Rhythm"},{"key":"ref_46","first-page":"1343","article-title":"The Ethics of Unilateral Implantable Cardioverter Defibrillators and Cardiac Resynchronization Therapy with Defibrillator Deactivation: Patient Perspectives","volume":"19","author":"Daeschler","year":"2017","journal-title":"EP Eur."},{"key":"ref_47","first-page":"2","article-title":"Considerations Involved in Elective Generator Replacement of Implantable Cardioverter-Defibrillators: Balancing Risks, Benefits, and Individual Factors","volume":"77","author":"Pombo","year":"2024","journal-title":"Rev. Esp. Cardiol. (Engl. Ed.)"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"791","DOI":"10.4065\/mcp.2010.0113","article-title":"Ethical Analysis of Withdrawing Ventricular Assist Device Support","volume":"85","author":"Mueller","year":"2010","journal-title":"Mayo Clin. Proc."},{"key":"ref_49","first-page":"100","article-title":"A Review of Ethical Considerations for Ventricular Assist Device Placement in Older Adults","volume":"4","author":"Bruce","year":"2013","journal-title":"Aging Dis."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"740","DOI":"10.1111\/aor.14452","article-title":"Outcome after Veno-Arterial Extracorporeal Membrane Oxygenation in Elderly Patients: A 14-Year Single-Center Experience","volume":"47","author":"Provaznik","year":"2023","journal-title":"Artif. Organs"},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Ayesta, A., Bonanad, C., D\u00edez-Villanueva, P., Garc\u00eda-Blas, S., Ariza-Sol\u00e9, A., and Mart\u00ednez-Sell\u00e9s, M. (2022). Ethical Considerations in Elderly Patients with Acute Coronary Syndrome. RCM, 23.","DOI":"10.31083\/j.rcm2302055"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1313","DOI":"10.1093\/eurheartj\/ehr083","article-title":"The Yentl Syndrome Is Alive and Well","volume":"32","author":"Merz","year":"2011","journal-title":"Eur. Heart J."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"832","DOI":"10.1016\/j.jacc.2004.11.055","article-title":"Gender Disparities in the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes: Large-Scale Observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology\/American Heart Association Guidelines) National Quality Improvement Initiative","volume":"45","author":"Blomkalns","year":"2005","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1016\/j.amjcard.2024.09.031","article-title":"Gender Disparities on the Use and Outcomes of Mechanical Circulatory Support in Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction","volume":"233","author":"Salguero","year":"2024","journal-title":"Am. J. Cardiol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1166","DOI":"10.1513\/AnnalsATS.202212-1029OC","article-title":"Disparities in Adult Patient Selection for Extracorporeal Membrane Oxygenation in the United States: A Population-Level Study","volume":"20","author":"Mehta","year":"2023","journal-title":"Ann. Am. Thorac. Soc."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"132730","DOI":"10.1016\/j.ijcard.2024.132730","article-title":"Sex Disparities in Myocardial Infarction Related Cardiogenic Shock","volume":"420","author":"Peters","year":"2025","journal-title":"Int. J. Cardiol."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"101946","DOI":"10.1016\/j.jacadv.2025.101946","article-title":"Family Engagement in Cardiac Intensive Care and Patient Outcomes","volume":"4","author":"Kandiah","year":"2025","journal-title":"JACC Adv."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"e010084","DOI":"10.1161\/CIRCOUTCOMES.123.010084","article-title":"Family Engagement in the Adult Cardiac Intensive Care Unit: A Survey of Family Engagement Practices in the Cardiac Critical Care Trials Network","volume":"16","author":"Goldfarb","year":"2023","journal-title":"Circ. Cardiovasc. Qual. Outcomes"},{"key":"ref_59","first-page":"e64151","article-title":"Health Disparities in Cardiac Critical Care: Understanding Inequities, Barriers, and Pathways Toward Equitable Access and Enhanced Outcomes","volume":"16","author":"Abouzid","year":"2024","journal-title":"Cureus"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1186\/s12939-021-01436-z","article-title":"The Convergence of Racial and Income Disparities in Health Insurance Coverage in the United States","volume":"20","author":"Lee","year":"2021","journal-title":"Int. J. Equity Health"},{"key":"ref_61","doi-asserted-by":"crossref","unstructured":"Tehrani, B.N., Epps, K.C., and Batchelor, W.B. (2024). An Uneven Playing Field: Demographic and Regionalized Disparities in Access to Device-Based Therapies for Cardiogenic Shock. J. Soc. Cardiovasc. Angiogr. Interv., 3.","DOI":"10.1016\/j.jscai.2023.101220"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"S91","DOI":"10.1016\/j.healun.2020.01.931","article-title":"Poor Social Support Confers Worse Survival after MCS","volume":"39","author":"Bryce","year":"2020","journal-title":"J. Heart Lung Transplant."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"378","DOI":"10.1016\/j.mpaic.2024.03.016","article-title":"Resource Allocation in Intensive Care","volume":"25","author":"Purvis","year":"2024","journal-title":"Anaesth. Intensive Care Med."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"103328","DOI":"10.1016\/j.iccn.2022.103328","article-title":"How to Communicate with Family Members of the Critically Ill in the Intensive Care Unit: A Scoping Review","volume":"74","author":"Reifarth","year":"2023","journal-title":"Intensive Crit. Care Nurs."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"623","DOI":"10.1016\/j.aucc.2021.10.010","article-title":"The Relationship between Person-Centred Care and the Intensive Care Unit Experience of Critically Ill Patients: A Multicentre Cross-Sectional Survey","volume":"35","author":"Kang","year":"2022","journal-title":"Aust. Crit. Care"},{"key":"ref_66","doi-asserted-by":"crossref","unstructured":"Rigaud, J.-P., Ecarnot, F., and Quenot, J.-P. (2023). Patient Information and Consent for Care in the Intensive Care Unit. Healthcare, 11.","DOI":"10.3390\/healthcare11050707"},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"103962","DOI":"10.1016\/j.iccn.2025.103962","article-title":"Communication with the Critically Ill Patient: A Nexus between Patient Needs, Communication Partner Skills and the ICU Environment","volume":"88","author":"Istanboulian","year":"2025","journal-title":"Intensive Crit. Care Nurs."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1016\/j.ccm.2022.05.008","article-title":"Patient-Centered and Family-Centered Care in the Intensive Care Unit","volume":"43","author":"Secunda","year":"2022","journal-title":"Clin. Chest Med."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"302","DOI":"10.1634\/theoncologist.5-4-302","article-title":"SPIKES-A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer","volume":"5","author":"Baile","year":"2000","journal-title":"Oncologist"},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"2391","DOI":"10.1007\/s10943-023-01746-2","article-title":"Spirituality in Critical Care: An Observational Study of the Perceptions of Professionals, Patients and Families, in Spain and Latin America","volume":"62","year":"2023","journal-title":"J. Relig. 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