ETHICAL & LEGAL DECISIONS IN CRITICAL CARE UNITS

Based on human principle of right & wrong

Ethical Standard

Based on written law

Legal Standard

emerged in the recent years as a major component of health care for the critically ill patients.

Ethical Decision Making

refers to the process of evaluating and choosing among alternatives in a manner consistent with ethical principles.

Ethical Decision Making

Nurses are expected to practice in an ethical manner, through the demonstration of a range of ethical competencies.

Ethical Issues in Critical Care

It is important that nurses develop a ‘moral competence’ so that they are able to contribute to discussion and implementation of issues concerning ethics and human rights in the workplaces .

Ethical Issues in Critical Care

Moral competence and ethical action is the ability to recognize that an ethical issue exists in a given clinical situation, knowing when to take ethical action if and when required, and a personal commitment to achieve moral outcomes

Ethical Issues in Critical Care

Autonomy

Non-maleficence

Beneficence

Veracity

Fidelity

Justice

Ethical Principles

Patient’s right to self determination.

Autonomy

do no harm.

Non-maleficence

promoting good

Beneficence

the obligation to tell the truth.

Veracity

faithfulness to agreements & responsibilities

Fidelity

the fair allocation of medical resources.

Justice

• Palliative Care

• CPR decisions

• Euthanasia

• Withholding & withdrawing treatment

• Futile care

Ethical Decision

• Identify source of authority for decision making.

• Achieve effective communication with patient and families

• Carry out early determination and ongoing review of patient’s desire.

• Clearly recognize patient’s rights.

• Carry out hospital policies.

• Protect the nurse’s own standards of care.

PRACTICAL PRINCIPLES FOR ETHICAL DECISION MAKING

• caring for a patient to relieve pain and make the dying process as peaceful as it can be.

• Depending on patients' wishes, they are given food and hydration.

Palliative Care

• Ethical questions on CPR: in what situations, for how long?

• Do not resuscitate (DNR): orders are commonly implemented in the critical care setting as a prelude to end-of-life care.

CPR Decision

a Greek word meaning “good death,” is popularly known as “mercy killing.”

Euthanasia

Active euthanasia

Passive euthanasia

Two Types of Euthanasia

never initiating a treatment

Withholding

to stop a treatment once started

Withdrawing

is the continued provision of medical care or treatment to a patient when there is no reasonable hope of a cure or benefit.

Futile Care

Medical documentation

Use of restraints

Declaring Brain death

Passive Euthanasia

Organ donation

Autopsy

Legal Decision in Critical Care Units

• Informed consent

• Advanced Directives

• Incident Reports

Medical Documentation

• “A patient’s legally binding treatment decision reached voluntarily and based on information about the risks , benefits and alternative treatments gained from discussion with a health care practitioner”

• Self determination or autonomy is the foundation of the legal and ethical doctrines of informed consent.

Informed Consent

• is a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions.

• These directives may also designate a specific surrogate decision maker who then has ethical and possibly legal standing to make medical decisions for the patient.

Advance Directives

• Living wills

• Health care proxy appointment/Durable power of attorney for heath care decision making.

Two Types of Advance Directives

• lists the interventions that the patient would request or reject in the future usually at the end of life”

• Most patients use living wills to refuse life sustaining care when the prognosis for improvement or recovery is hopeless

• specifies a set of circumstances followed by set of consequences

Living will

is a legal document that allows a person to appoint a person called a health care agent or proxy, to make health care decisions should the patient become temporarily or permanently incapacitated or be declared legally incompetent”

A durable power of attorney for health care or health care proxy

• It means a doctor is not required to resuscitate a patient if their heart stops.

• It is useful in preventing unnecessary and unwanted invasive interventions at the end of life.

• Nurses need to clarify the patient and health care proxy that only CPR will not be given but other interventions will be carried .

Do not Resuscitate

• Document the occurrence of anything out of the ordinary that results in, or has the potential result in, harm to a patient, employee or visitor.

• The nurse responsible for a potentially or actually harmful incident or who witnesses an injury is the one who fills out the incident form.

Incident Report

• Intervention that limits a person’s freedom to move

• Physical or chemical.

• Use only when all other methods have failed

• as a last resort

• use least restrictive method possible

Use of Restraint

• Require a physician not involved in the patient treatment to document brain death and another physician to confirm the findings

Declaring Brain Death

• coma,

• absence of brainstem reflexes,

• and apnea.

Three Essential Findings in Brain Death

• The donation can be made by a provision in a will or by signing a card-like form.

• Nurses may serve as witnesses for people consenting to donate organs.

Organ Donation Decision