Clinical Decision-Making, Financial Incentives, and Ethical Challenges in the Escalation of Mechanical Ventilation: A PRISMA-Guided Review

Abstract

Background: Mechanical ventilation is a life-saving intervention in critical care; however, decisions regarding its escalation are complex and influenced by clinical uncertainty, ethical challenges, and health system constraints. Increasing concerns have emerged regarding potential overutilization and its impact on patient outcomes and healthcare resources. Objective: To synthesize available evidence on clinical decision-making, financial influences, and ethical dilemmas associated with the escalation of invasive mechanical ventilation in adult critical care settings. Methods: A focused literature review guided by PRISMA 2020 principles was conducted using PubMed, Scopus, and Google Scholar. Studies addressing clinical, ethical, and economic aspects of mechanical ventilation were included and narratively synthesized. Results: The evidence indicates substantial variability in ventilation practices driven by prognostic uncertainty, institutional incentives, and resource pressures. Proactive ethics consultation and structured decision aids improved communication, reduced non-beneficial treatment, and shortened ICU length of stay. Longterm outcomes of prolonged mechanical ventilation were poor, with high mortality and limited functional recovery among survivors. Conclusion: Escalation of mechanical ventilation is shaped by intersecting clinical, ethical, and systemic factors. Integrating ethical frameworks, shared decision-making, and evidence-based de-escalation strategies is essential to promote patient-centered and ethically sound critical care.