Background: The decision whether to initiate intensive care for the critically ill patient involves ethical questions regarding what is good and right for the patient. It is not clear how referring doctors negotiate these ethical questions in practice.

Objectives: To illuminate the meaning of senior referring doctors´ lived experiences of decision-making about whether to initiate intensive care treatment. 

Methods: Analysis, using a phenomenological hermeneutical method, of interviews with 27 senior doctors from departments regularly referring patients to intensive care in six British hospitals. The interviews were conducted as part of the larger research project ‘Understanding and improving the decision-making process surrounding admission to the intensive care unit’, funded by the National Institute of Health Research, UK.

Results: Senior doctors struggle with the complex decision-making process when they are in doubt whether escalation to intensive care for the critically ill patient would be beneficial. A trusted process requires senior, mutual responsiveness between the referring doctor and the intensivist. Within the professional vulnerability created by the burdensome uncertainty of not being sure what is good and right for the patient, moral responsibility is secured through clinical proximity, and confidence is gained through responsive interaction.

Conclusions: Decision-making requires a reliable process based on mutual responsiveness and proximity. To promote this, an organizational structure and culture is needed where mutual recognition and support between decision-makers are valued.