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Annette Robertsen

Associate Professor - Centre for Medical Ethics

Email annette.robertsen@medisin.uio.no

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Visiting address Gaustadalléen 21 Forskningsparken Hus C Plan 1 0349 Oslo

Postal address Postboks 1130 Blindern 0318 Oslo

Other affiliations LINK-Centre for Learning and Education (Student)

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Academic interests

Clinical ethics. Choosing wisely. Decisionmaking processes regarding withholding or withdrawing of life-sustaining treatment. Potentially inappropriate treatment. Strategies for dealing with uncertainty and doubt related to ethical dilemma. Interprofessional collaboration. Autonomy. Vulnerability. Family-centered care. End-of-life care in the intensive care unit. A good death. Organdonation. Medical errors. Moral distress. Moral resilience. Peer support.

Teaching

Lectures on medical ethics topics for medical students at the University of Oslo, lectures on medical ethics topics for physicians and nurses as part of my clinical work, teaching physicians in specialist training for the Norwegian medical association, some teaching for the ethic section in the European Society of Intensive Care Medicine

Background

I studied medicine at the University of Oslo (1986-92) and I have since then worked as a physicians (1992 - now). I worked for 3 years with internal medicine (1995-1998), but changed to anesthesiology (1998 - now). I am a specialist in anesthesiology and in intensive care medicine with a European diploma of intensive care (EDIC from 2006), my clinical work is full time in the intensive care unit. I have my PhD from the University of Oslo, with the project treatment-limiting decisions in patients with traumatic brain injury, supervisions professor Reidun Førde, Center of Medical Ethics University of Oslo and Eiric Helseth, professor of neurosurgery, Oslo University Hospital.

Positions held

Senior consultant in the intensive care unit Oslo University Hospital, Oslo, Norway and associate professor (part time) at the Center for medical ethics, University of Oslo, Norway

Collaboration

I am a member of the ethics section of the European Society of intensive care medicine (ESICM), contributed to ESICM e modules in medical ethics and a book chapter written in collaboration with collegues from the ethics section og ESICM

I was the Norwegian national coordinator for the ETHICUS II study on end-of-life care in the intensive care unit, an international multi-center study lead by Charles Sprung Israel, 11 Norwegian sites participated

I am part of the clinical ethics group in Center of medical ethics, University of Oslo

I am part of the intensive care reasearch group at Oslo University Hospital

I collaborate with researchers at St Olav, Trondheim, Norway on a project on dying in hospital - experiences and processes, the IHOD project, ongoing, in planning phase

Robertsen, Annette; Gardiner, Dale & Whetstine, Leslie (2026). Intensive care staff: the gatekeepers to donation after circulatory death. Intensive Care Medicine. ISSN 0342-4642. doi: 10.1007/s00134-025-08264-7. Full text in Research Archive Show summary
Editorial related to Grossi et al paper on attitudes to donation after circulatory death highlighting key elements for promoting positive ICU staff support towards controlled DCD
Benbenishty, Julie; Ganz, Freda DeKeyser; Lautrette, Alexandre; Jaschinski, Ulrich; Aggarwal, Avneep & Søreide, Eldar [Show all 15 contributors for this article] (2024). Variations in reporting of nurse involvement in end-of-life practices in intensive care units worldwide (ETHICUS-2): A prospective observational study. International Journal of Nursing Studies. ISSN 0020-7489. 155. doi: 10.1016/j.ijnurstu.2024.104764. Full text in Research Archive
Feldman, Charles; Sprung, Charles L.; Mentzelopoulos, Spyros D.; Pohrt, Anne; Hartog, Christiane S. & Danbury, Christopher [Show all 26 contributors for this article] (2022). Global comparison of communication of end-of-life decisions in the ICU. Chest. ISSN 0012-3692. 162(5), p. 1074–1085. doi: 10.1016/j.chest.2022.05.007. Full text in Research Archive
Avidan, Alexander; Sprung, Charles L.; Schefold, Joerg C; Ricou, Bara; Hartog, Christiane & Nates, Joseph L [Show all 47 contributors for this article] (2021). Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study. The Lancet Respiratory Medicine. ISSN 2213-2600. 9(10), p. 1101–1110. doi: 10.1016/S2213-2600(21)00261-7. Full text in Research Archive
Robertsen, Annette; Helseth, Eirik & Førde, Reidun (2021). Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see. BMC Medical Ethics. 22(1). doi: 10.1186/s12910-021-00612-8. Full text in Research Archive Show summary
Background Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. Methods Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making. Results A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team—family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. Conclusions Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.
Benbenishty, Julie; Ganz, Freda DeKeyser; Anstey, Matthew H.; Barbosa-Camacho, Francisco Jose; Bocci, Maria Grazia & Çizmeci, Elif Ayşe [Show all 15 contributors for this article] (2021). Changes in intensive care unit nurse involvement in end of life decision making between 1999 and 2016: Descriptive comparative study. Intensive and Critical Care Nursing. ISSN 0964-3397. 68. doi: 10.1016/j.iccn.2021.103138. Full text in Research Archive
Dahlberg, Jørgen; Eriksen, Camilla; Robertsen, Annette & Beitland, Sigrid (2020). Barriers and challenges in the process of including critically ill patients in clinical studies. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 28(1), p. 51–51. doi: 10.1186/s13049-020-00732-x. Full text in Research Archive Show summary
Background Clinical research in severely ill or injured patients is required to improve healthcare but may be challenging to perform in practice. The aim of this study was to analyse barriers and challenges in the process of including critically ill patients in clinical studies. Methods Data from critically ill patients considered for inclusion in an observational study of venous thromboembolism in Norway were analysed. This included quantitative and qualitative information from the screening log, consent forms and research notes. Results Among 279 eligible critically ill patients, 204 (73%) were omitted from the study due to challenges and barriers in the inclusion process. Reasons for omission were categorised as practical in 133 (65%), medical in 31 (15%), and legal or ethical in 40 (20%) of the patients. Among 70 included patients, 29 (41%) consents were from patients and 41 (59%) from their next of kin. Several challenges were described herein; these included whether patients were competent to give consent, and which next of kin that should represent the patient. Furthermore, some included patients were unable to recall what they have consented, and some appeared unable to separate research from treatment. Conclusions Barriers and challenges in the inclusion process led to the omission of near three out of four eligible patients. This analysis provided information about where the problem resides and may be solved. The majority of challenges among included patients were related to issues of autonomy and validity of consent. Trial registration ClinicalTrials.gov (NCT03405766).
Kerckhoffs, Monika C.; Senekal, Jannien; Dijk, Diederik Van; Artigas, Antonio; Butler, Jenie & Michalsen, Andrej [Show all 13 contributors for this article] (2020). Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study. Critical Care Medicine. ISSN 0090-3493. p. 645–653. doi: 10.1097/CCM.0000000000004221. Full text in Research Archive
Solbakk, Jan Helge; Bentzen, Heidi Beate; Holm, Søren; Heggestad, Anne Kari Tolo; Hofmann, Bjørn Morten & Robertsen, Annette [Show all 10 contributors for this article] (2020). Back to WHAT? The role of research ethics in pandemic times. Medicine, Health care and Philosophy. ISSN 1386-7423. p. 1–16. doi: 10.1007/s11019-020-09984-x. Full text in Research Archive Show summary
The Covid-19 pandemic creates an unprecedented threatening situation worldwide with an urgent need for critical reflection and new knowledge production, but also a need for imminent action despite prevailing knowledge gaps and multilevel uncertainty. With regard to the role of research ethics in these pandemic times some argue in favor of exceptionalism, others, including the authors of this paper, emphasize the urgent need to remain committed to core ethical principles and fundamental human rights obligations all reflected in research regulations and guidelines carefully crafted over time. In this paper we disentangle some of the arguments put forward in the ongoing debate about Covid-19 human challenge studies (CHIs) and the concomitant role of health-related research ethics in pandemic times. We suggest it might be helpful to think through a lens differentiating between risk, strict uncertainty and ignorance. We provide some examples of lessons learned by harm done in the name of research in the past and discuss the relevance of this legacy in the current situation.
Robertsen, Annette (2020). Consent, Advance Directives, and Decision by Proxies. In Michalsen, Andrej (Eds.), Compelling Ethical Challenges in Critical Care and Emergency Medicine. Springer. Full text in Research Archive
Robertsen, Annette; Helseth, Eirik; Laake, Jon Henrik & Førde, Reidun (2019). Neurocritical care physicians' doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: An interview study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 27:81, p. 1–8. doi: 10.1186/s13049-019-0648-9. Full text in Research Archive Show summary
Background Multilevel uncertainty exists in the treatment of devastating brain injury and variation in end-of-life decision-making is a concern. Cognitive and emotional doubt linked to making challenging decisions have not received much attention. The aim of this study was to explore physicians´ doubt related to decisions to withhold or withdraw life-sustaining treatment within the first 72 h after devastating brain injury and to identify the strategies used to address doubt. Method Semi-structured interviews were conducted with 18 neurocritical care physicians in a Norwegian trauma centre (neurosurgeons, intensivists and rehabilitation specialists) followed by a qualitative thematic analysis. Result All physicians described feelings of doubt. The degree of doubt and how they dealt with it varied. Institutional culture, ethics climate and individual physicians´ values, experiences and emotions seemed to impact judgements and decisions. Common strategies applied by physicians across specialities when dealing with uncertainty and doubt were: 1. Provision of treatment trials 2. Using time as a coping strategy 3. Collegial counselling and interdisciplinary consensus seeking 4. Framing decisions as purely medical. Conclusion Decisions regarding life-sustaining treatment after devastating brain injury are crafted in a stepwise manner. Feelings of doubt are frequent and seem to be linked to the recognition of fallibility. Doubt can be seen as positive and can foster open-mindedness towards the view of others, which is one of the prerequisites for a good ethical climate. Doubt in this context tends to be mitigated by open interdisciplinary discussions acknowledging doubt as rational and a normal feature of complex decision-making.
Robertsen, Annette; Førde, Reidun; Skaga, Nils Oddvar & Helseth, Eirik (2017). Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 25(44), p. 1–9. doi: 10.1186/s13049-017-0385-x. Full text in Research Archive Show summary
Background Treatment-limiting decisions (TLD) for severe traumatic brain injury (sTBI) have been sparsely studied. This study determine prevalence, main reason for, categories and timing of TLDs in a Norwegian regional trauma setting. Methods A retrospective study of a 2-year cohort of 579 sTBI patients admitted to Oslo University Hospital (OUH). Prospectively collected data in the OUH Trauma Registry were combined with retrospective data from a chart review regarding TLDs. Results TLDs were documented for 101/579 sTBI patients (17%). The situation was evaluated as futile in 59 cases and as potentially inappropriate in 42 cases. The three most frequent types of TLDs were withholding of neurosurgery, do not resuscitate orders and withdrawing of organ support. In 70% of cases, the first TLD was made within 2 days after injury, while in 14%, the first TLD was made later than day 7. Twenty percent (20/101) of the first TLDs were later adjusted, revoked in 4 patients and broadening of TLDs in 16 patients. The median time from the decision to death was 2 days (range 1–652). TLDs were documented in 93% of in-hospital death cases (n = 79). In-hospital deaths occurred in 73% of TLD group cases and 1% of non-TLD group cases. Family interaction and multi-team discussions were documented in >88% of cases, but no advanced directives were found, and notifications of patients’ preferences were found in only 7% of cases. Discussion Clinicians should consider limiting treatment if continued treatment is not in the patients best interest. A range of different types of TLDs were applied for patients after sTBI in the trauma hospital setting. Conclusion TLDs were found in 17% of sTBI patients. Value considerations behind TLDs in this care context need to be further explored.

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Benbenishty, Julie; Ganz, Freda DeKeyser; Anstey, Matthew H.; Barbosa-Camacho, Francisco Jose; Bocci, Maria Grazia & Çizmeci, Elif Ayşe [Show all 15 contributors for this article] (2022). We need to better recognise and value the contribution of nurses to end-of-life care (Bloomer, ICCN 2022). Intensive and Critical Care Nursing. ISSN 0964-3397. 70. doi: 10.1016/j.iccn.2022.103225. Full text in Research Archive
Solbakk, Jan Helge; Bentzen, Heidi Beate; Holm, Søren; Heggestad, Anne Kari Tolo; Hofmann, Bjørn Morten & Robertsen, Annette [Show all 10 contributors for this article] (2020). Høyrisikostudier på alle mennesker i Covid-19-sammenheng er etisk uforsvarlig. Full text in Research Archive
Robertsen, Annette; Reinlie, Sissel; Hanoa, R. & Nordby, Hans-Kristian (2013). Kritiske beslutninger om behandlingsnivå ved alvorlig traumatisk hjerneskade. In Hanoa, R. (Eds.), Nevrotraumatologi. Fagbokforlaget. ISSN 9788245010084. Full text in Research Archive
Robertsen, Annette; Sørensen, Dag Wendelbo & Hanoa, R. (2013). Organdonasjon. In Hanoa, R. (Eds.), Nevrotraumatologi. Fagbokforlaget. ISSN 9788245010084. Full text in Research Archive