ethical issues in critical care nursing

Many clinical scenarios invite ethical reflection and raise questions about health professionals’ decision making and behaviour, as distinct from specific diagnostic or technical questions. An advance health care directive, also known as a living will, personal directive, advance directive or advance decision, are instructions given by individuals specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to illness or incapacity, and appoints a person to make such decisions on their behalf. A competent individual has the right to decline or accept healthcare treatment. Less than 10% of doctors and nurses would like their life prolonged by all available means, compared to 40% of patients and 32% of families. Dilemmas arise when there are disparate views within the team as to what constitutes ‘futility’ and with associated decisions regarding the next step or steps when a patient’s outlook is at its most grave. statute law or legislation (i.e. Both withholding and withdrawing of life support was practised by the majority of European intensivists while active life ending procedures despite occurring in a few cases remained rare.38 The ethics of withdrawal of treatment are discussed in detail in the ANZICS Statement on Withholding and Withdrawing Treatment.34 The NHMRC publication entitled Organ and Tissue Donation, After Death, for Transplantation: Guidelines for Ethical Practice for Health Professionals provides further discussion of the ethics of organ and tissue donation.44. Levine, M.E. Interdisciplinary Education on Discussing End-of-Life Care . Teaching Ethics. New Zealand and most states of Australia have an Act that allows for the appointment of a person to hold enduring power of attorney.52 It is found in the literature that most individuals do not want to write advanced directives and are hesitant to document their end of life care desires. With respect to negligence, the amount of information about risks required is that deemed by the court to be ‘reasonable’ in light of the choices that patients confront.25, If a person is assessed as not being competent, consent must be sought from someone who has lawful authority to consent on his or her behalf. In principle, any procedure that involves intentional contact by a healthcare practitioner with the body of a patient is considered an invasion of the patient’s bodily integrity, and as such requires the patient’s consent. Individuals commonly want their family to decide for them, although the judgement of intensive care professionals concerning which treatment should be given may well differ from that of patients and families. Many families want to be involved but some individual family members do not want to be involved in end-of-life decisions. The fair, equitable and appropriate distribution of health care, determined by justified rules or ‘norms’, is termed distributive justice.6 There are various well-regarded theories of justice. Although some nurses draw a distinction between ethics and morality, there is no philosophical difference between the two terms, and attempting to make a distinction can cause confusion. Nurses fulfil the accountability and responsibility inherent in their roles. c. patient before hospitalization. In the US35–37 and Europe38 the majority of doctors have withheld or withdrawn life-sustaining treatments. It should also be noted that nurses must seek consent for all procedures that involve ‘doing something’ to a patient (e.g. A living will is one form of advance directive, leaving instructions for treatment. It should be noted that each Australian state and territory has differences in its Acts, which can cause confusion. All are applicable to critical care practice. 1, Manuscript 1. Another form authorises a specific type of power of attorney or health care proxy, where someone is appointed by the individual to make decisions on their behalf when they are incapacitated. Accounts of informed consent in medical ethics claim that it is valuable because it supports individual autonomy yet there are distinct conceptions of individual autonomy, and their ethical importance varies. The best interests principle relies on the decision makers possessing and articulating an understanding or account of quality of life that is relevant to the patient in question, particularly in making end-of-life decisions. After the physician leaves, the patient, who is visibly shaken, asks the nurse, Couldnt the doctor be wrong? Anna Falcó-Pegueroles . the level to which basic needs are met, such as avoiding harm, and adequate nutrition and shelter). pp 216-232 | The incidence of withholding and withdrawal of life support from critically ill patients has increased to the extent that these practices now precede over half the deaths in many ICUs. Chapter 7- Ethical Issues in Critical Care Nursing My Nursing Test Banks . To show lack of respect for an autonomous agent, or to withhold information necessary to make a considered judgement, when there are no compelling reasons to do so, is to repudiate that person’s judgements. Because ethical positions are fundamentally based on an individual’s own beliefs and ethical perspective, it may be difficult to gain a consensus view on a complex clinical situation, such as withdrawal of treatment. The fair, equitable and appropriate distribution of health care, determined by justified rules or ‘norms’, is termed distributive justice. Kendrick, K. and Cubbin, B. There is a risk that nurses may become socialised into a prevailing culture and associated thought processes, such as the particular work group on their shift, the unit where they are based, or the institution in which they are employed. Directors and managers of ICU units have several ethics teaching options. Critical care staff need to be trained in assessing the most critical cases and providing sufficient medical care for patients who may recover. 23, No. Obtaining consent is part of the overall duty of care.11, In recent decades, research in the biomedical sciences has been increasingly located in settings outside of the global north. As the provision of care to the critically ill becomes more complex due to technological advancement, and the profession of nursing more Ethics are quite distinct from legal law, although these do overlap in important ways. Marshall, J. While technology is capable of maintaining some of the vital functions of the body, it may be less able to provide a cure. Bedell, S.E. An understanding of the principle of consent is necessary for nurses practising in critical care. The use of the basic ethical principles in these administrative issues may be less familiar. 1. However, some persons are in need of extensive protection, depending on the risk of harm and likely benefit of protecting them, and in these cases paternalism may be considered justifiable.6,7, According to the principle of autonomy, critical care patients are entitled to be treated as self-determining. Discussion: legal and ethical issues in handling and reporting. Acts of Parliament); Statute law has particular relevance to ethics in the critical care context. An understanding of the principle of consent is necessary for nurses practising in critical care. However, some persons are in need of extensive protection, depending on the risk of harm and likely benefit of protecting them, and in these cases paternalism may be considered justifiable. Enduring guardians can potentially make a wider range of decisions than a medical agent, but an enduring guardian can make decisions only once a person is considered to be unable to make his/her own decisions. Conditions of scarcity and competition result in the predominant problems associated with distributive justice. A general distinction can be made between civil law jurisdictions, which codify their laws, and common law systems, where judge-made law is not consolidated. With advances in technology in health care, it is possible more than ever before to restore, sustain and prolong life with the use of complex technology and associated therapies, such as mechanical ventilation, extracorporeal oxygenation, intra-aortic balloon counterpulsation devices, haemodialysis and organ transplantation. Nurses are autonomous moral agents, and at times may adopt a personal moral stance that makes participation in certain interventions or procedures morally unacceptable (see the Conscientious objection section later in this chapter). be given by a person legally competent to do so. Some doctors do not communicate with patients or families or document decisions because of the lack of clear laws for end-of-life practices and the fear of litigation. Although assumptions are commonly made that a shared understanding of the concept of quality of life exists, it may be that the patient’s perspective on what gives his or her life meaning is quite different from that of other people. Nurses hold in confidence any information obtained in a professional capacity, use professional judgement where there is a need to share information for the therapeutic benefit and safety of a person, and ensure that privacy is safeguarded. BioethicsLine: 1972-1999 Seeking consent in this type of everyday situation is less formal than obtaining consent for a surgical intervention, although it still represents ethically (and legally) prudent practice. If the courts have appointed a person to be a guardian for an incompetent individual, then the guardian can provide consent on behalf of that individual. Search Google Scholar for this author, Teresa Lluch-Canut. In Australia this predominantly includes the National Health and Medical Research Council (NHMRC) and the National Statement on Ethical Conduct in Human Research (2007);8 while in New Zealand it is by the Health Research Council of New Zealand (HRCNZ), Guidelines on Ethics in Health Research and the HRCNZ Operational Standard for Ethics Committee (OS).26,27 In the UK guidance is provided by the General Medical Council.24 In the US there are required elements of written Institutional Review Board (IRB) procedures under Department of Health and Human Services (HHS) regulations for the protection of human subjects and relevant Office for Human Research Protections (OHRP) Department of Health and Human Services ‘guidance’ regarding each required element. Each of these types of consent has differing requirements. To deny a competent individual autonomy is to treat that person paternalistically. Consent may relate to healthcare treatment, participation in human research and/or use and disclosure of personal health information. International Conference on Critical Care Nursing and Ethical Issues scheduled on October 07-08, 2022 at Tokyo, Japan is for the researchers, scientists, scholars, engineers, academic, scientific and university practitioners to present research activities that might want to attend events, meetings, seminars, congresses, workshops, summit, and symposiums. Bergum, V. (1994) ‘Knowledge for ethical care’. The New Zealand Code particularly notes that nurses need to practise in a manner that is ‘culturally safe’ and that they should practise in compliance with the Treaty of Waitangi. End-of-life decision making is usually very difficult and traumatic. Hence, decisions regarding withdrawal and withholding of life support treatment(s) are not made without substantial consideration by the critical care team. If the courts have appointed a person to be a guardian for an incompetent individual, then the guardian can provide consent on behalf of that individual. Rather, the role of proxy tends to be assumed on the basis of an existing relationship between proxy and patient. 3. In addition, individual preferences may change over time. Depending on the prevalent culture at any one of these levels, nursing practice may be highly ethical or less ethically justifiable. (1994) ‘Ethical decision-making in intensive care: a nurse’s perspective’. The protections that medical and research ethics offer in these contexts tend to be modelled on a western tradition in which individual informed consent is paramount and are usually phrased in legal and technical requirements. For example, codes relevant to nurses have been developed by the Australian Nursing and Midwifery Council (2002)61 and the International Council of Nurses (2002)14 (see Box 5.1). Given the complexity of contemporary healthcare environments, it is vital that nurses are a… As with formally appointed guardians, the powers of a ‘person responsible’ are limited by statute.19. Consent may relate to healthcare treatment, participation in human research and/or use and disclosure of personal health information. In any given decision-making situation, the participants hold different presumptions about their roles in the process, different frames of reference based on different levels of knowledge, and different amounts of relevant experience.45 Nurses, for example, may conform to the dominant culture in order to create opportunities to participate in decision making, and thereby may conform to the values and norms of medicine. Another form authorises a specific type of power of attorney or health care proxy, where someone is appointed by the individual to make decisions on their behalf when they are incapacitated. Observational studies demonstrate that North American health care workers consult families more often than do European workers,39,41 and some seriously ill patients wish to participate in end of life decisions whilst others do not.42, In most cases where there is doubt about the efficacy and appropriateness of a life-sustaining treatment, it may be considered preferable to commence treatment, with an option to review and cease treatment in particular circumstances after broad consultation. Organisations such as the Global Forum for Bioethics in Research, the Forum for Ethical Review Committees in the Asia Pacific Region and the World Health Organization have sought to improve oversight of research projects, refine regulation and guidance, address cultural variation, educate the public about research and strengthen ethical review committee structures according to internationally acknowledged ‘benchmarks’.4,5. The thrust of this chapter is to explore research findings about issues that cause ethical concern for critical care nurses in Europe. • Discuss ethical principles as they relate to critical care patients. Ethical issues have emerged in the recent years as a major component of health care for the critically ill patients, who are vulnerable and totally depend on nurse working in the critical care unit. The ‘group think’ approach of ‘That’s how we’ve always done it’ requires critical reflection on what is the ethical or ‘right thing to do’. A healthcare practitioner must not assume that a patient provides a valid consent on the basis that the individual has been admitted to a hospital. Difficulties related to this principle include that making an accurate substituted judgement is very difficult, and that the proxy might not be the most appropriate person to have taken on the role.51, For individuals wanting to document their preferences regarding future healthcare decisions with the onset of incompetence, there are ‘anticipatory direction’ and ‘advance directive’ forms available. Moral rightness or wrongness may be quite distinct from legal rightness or wrongness, and although ethical decision making will always require consideration of the law, there may be disagreement about the morality of some law. In critical care nursing, there are ethical issues that come up all of the time. Brown, C. (1990) ‘Limiting care: is CPR for everyone?’. Not logged in Consent should never be implied, despite the fact that the patient is in a critical care area. ORDER NOW FOR CUSTOMIZED NURSING ESSAY PAPERS ON Discussion: legal and ethical issues in handling and reporting. Legal systems elaborate rights and responsibilities in a variety of ways. Nursing codes of ethics incorporate such an understanding of patient’s rights. and Sibbald, W.J. The first stage in this process will be to explore the preparation of critical care nurses to deal with ethical issues and to identify the nature and essence of nursing ethics in relation to the delivery of critical care. In an emergency, healthcare treatment may be provided without the consent of any person, although ‘emergency’ has not routinely been formally defined. Over 10 million scientific documents at your fingertips. These are: • statute law or legislation (i.e. Study Flashcards On Ethical and Legal Issues in Critical Care Nursing at Cram.com. A case is presented that highlights 2 common ethical challenges seen in the intensive care unit: symptom management in the noncommunicative patient and medical futility. One of the most effective ways of teaching nurses and doctors how to handle ethical … Consent is considered valid when the following criteria are fulfilled; consent must: • be informed (the patient must understand the broad nature and effects of the proposed intervention and the material risks it entails). • Describe what constitutes an ethical dilemma. When asked where they would rather be if they had a terminal illness with only a short time to live, more doctors and nurses preferred being home or in a hospice and more patients and families preferred being in an ICU. Because of the vulnerable nature of the critically ill individual, direct informed consent is often difficult, and surrogate consent may be the only option, particularly in an emergency. a living will) or proxy (the appointment of a person(s) with enduring power of attorney to act as surrogate decision maker), or some combination of both. In health care, egalitarian theories generally propose that people be provided with an equal distribution of particular goods or services. There are also articles concerning end-of-life care and cardiopulmonary resuscitation. Artificial hydration and … In practice this means that although the caregiver’s treatment is aimed to ‘do no harm’, there may be times where to ‘maximise benefits’ for positive health outcomes it is considered ethically justifiable that the patient be exposed to a ‘higher risk of harm’ (albeit ‘minimised’ by the caregiver as much as possible). Where the patient is incompetent, healthcare professionals ought to act so as to respect the autonomy of the individual as much as possible, for example by attempting to discover what the patient’s preference would have been in the current circumstances. Mass critical care planning has occurred at the regional (2), state/provincial (3, 4), national (5–7), and international (8) levels. Advance directives can be signed only by a competent person (before the onset of incompetence), and can be either instructional (e.g. Much of this research arises out of transnational collaborations made up of sponsors in high income countries (pharmaceutical industries, aid agencies, charitable trusts) and researchers and research subjects in low- to middle-income ones. However, even for formally-appointed guardians, certain procedures are not allowed and the consent of a guardianship authority is required. The majority of the community and doctors favour active life-ending procedures for terminally-ill patients.39,40 In the Ethicatt study, questionnaires on end of life decision-making were given to 1899 doctors, nurses, patients who were in ICUs and family members of the patients in six European countries. While it is essential that all members of the critical care team be able to contribute and be heard, the final decision (and ultimately legal accountability in Australia and New Zealand for the act of withdrawal of therapy) rests with the treating medical officer. For example, in the coronary care unit (CCU) a patient may require a central venous catheter (CVC) to optimise fluid and drug therapy, but this is not without its own inherent risks (e.g. Individuals should be treated as autonomous agents; and individuals with diminished autonomy are entitled to protection. Discuss with your colleagues the legal and ethical issues in handling and reporting [to whom] impaired health care providers. ‘Statements of patients’ rights’ relate to particular moral interests that a person might have in healthcare contexts, and hence require special protection when a person assumes the role of a patient. Nurses fulfil the accountability and responsibility inherent in their roles. (1995) ‘Creating an ethical practice environment: a focus on advocacy’. End-of-life decision making is usually very difficult and traumatic. The patient relies on the professional’s expertise, knowledge and advice, but it is up to the patient to decide whether he/she will accept or reject treatment, or in some circumstances request that the professional make the decision. What may be adopted legally and ethically or morally in one country may not be acceptable in another. When science travels, so does its ethics. Despite the importance placed on quality of life in terms of its influence in the decision-making process, it is difficult to articulate a common understanding of the concept. Unable to display preview. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Presurgical Functional MappingAndrew C. Papanicolaou, Roozbeh Rezaie, Shalini Narayana, Marina Kilintari, Asim F. Choudhri, Frederick A. Boop, and James W. Wheless, the Child With SeizureDon K. Mathew and Lawrence D. Morton, and Pharmacologic Consequences of SeizuresShilpa D. Kadam and Michael V. Johnston, Self-Limited EpilepsiesDouglas R. Nordli, Jr., Colin D. Ferrie, and Chrysostomos P. Panayiotopoulos, in Epilepsy: A Network and Neurodevelopmental PerspectiveRaman Sankar and Edward C. Cooper, Hematology, Oncology and Palliative Medicine, understand the diversity and complexities of ethical issues involving critical care practice, understand key ethical principles and how to apply them in everyday practice as a critical care registered nurse, be aware of the availability and access to additional resource material that may inform and support complex ethical decisions in clinical practice, discuss the ethical implications of the organ donation for transplantation decision-making process, understand consent and guardianship issues in critical care. A case study incorporating ethical conflicts demonstrates use of this model. (ed.). All discussions should be recorded in the medical records including the basis for the decision, who has been involved and the specifics of treatment(s) being withheld or withdrawn. Conditions of scarcity and competition result in the predominant problems associated with distributive justice. In addition, new medication treatment options contribute significant promises of added benefits, and fewer side effects, and are heralded by drug companies and journals across the world. administering an injection), and should be wary of relying on ‘implied’ consent. Nurses value environmental ethics and a social, economic and ecologically sustainable environment that promotes health and wellbeing. The principle of beneficence requires that nurses act in ways that promote the wellbeing of another person; this incorporates the two actions of doing no harm, and maximising possible benefits while minimising possible harms (non-maleficence).8 It also encompasses acts of kindness that go beyond obligation. If there is no guardianship order then, strictly speaking, consents for healthcare treatment may be given only by the guardianship authority. Safe delivery of those therapies is often the nurse’s responsibility, which is distinct from the medical order issued to commence the treatment. 26 Ethical and Legal Issues in Critical Care Nursing Jayne M. Willis, MSN, RN, NEA-BC Kathy Black, MSN, RN, NE-BC INTRODUCTION Critical care nurses are often confronted with ethical and legal dilemmas related to informed consent, withholding or withdrawing life-sustaining treatment, organ and tissue transplantation, confidentiality, and increasingly, justice in the distribution of healthcare resources. The role of critical care nurses in relation to ethical issues has become increasingly complex. Dimingo, J. Yet, when cast against a wider backdrop of global health, economic inequalities and cultural diversity, such models often prove limited in effect and inadequate in their scope. For incompetent individuals, the situation is less clear and varies between jurisdictions. Google Scholar | Medline Consent to conduct research involving unconscious individuals (incompetent adults) in critical care is one of the situations not comprehensively covered in most legislation (see also Ethics in research later in this chapter). Despite significant advances in medical technology and therapeutics, approximately 20% of patients admitted to ICUs do not survive and the majority of those die in ICU after the forgoing of life-prolonging therapies (as opposed to after cardiopulmonary resuscitation). Kendrick, K. (1994a) ‘Building bridges: teaching ward-based ethics’. The New Zealand Bill of Rights and the Health Act 1956 are currently under revision in New Zealand.12,13 These documents can be accessed via the New Zealand Ministry of Health (www.hon.govt.nz). In Australia, when active treatment is withdrawn or withheld, legally the same principles apply. Doctors daily make judgements regarding their patients’ competency to consent to medical investigation and treatment, and in today’s litigious climate they must face the possibility that, from time to time, these decisions will be examined critically in a court of law. Many entities frame their recommendations in terms of ethical principles and articulate similar substantive and procedural norms (9, 10). The nurse respects the rights of patients/clients. Current Students; New Nursing Students; Aspiring Students; Vlog; Med Math; iStudentNurse.com | Ethical and Legal Issues in Critical Care. Critical care nurses should maintain awareness of the ethical principles that apply to their clinical practice. Because of this difficulty, there is sometimes a lack of consistency and objectivity in the initiation, continuation and withdrawal of life-supporting treatment in a critical care setting.30 Traditionally, a paternalistic approach to decision making has dominated, but this stance continues to be challenged as greater recognition is given to the personal autonomy of individual patients.9, Decision making in the critical care setting is conducted within, and is shaped by, a particular sociological context. It should also be noted that nurses must seek consent for all procedures that involve ‘doing something’ to a patient (e.g. Critical care nurses are encouraged to participate in discussion and educational opportunities regarding ethics in order to provide clarity in relation to fulfilment of their moral obligations. Teresa Lluch-Canut. in relation to individual autonomy and informed consent, needs to take account of cultural values, while respecting absolutely the ethical standards. Assessment of their ‘post-critical illness’ quality of life is complex, emotive and forms the basis of significant debate, compounded by the nuances of each individual patient’s case. University of Barcelona, Spain See all articles by this author. Nurses accept the rights of individuals to make informed choices in relation to their care. Ethical justification of the best interests principle therefore requires a relevant and current understanding of what quality of life means to the particular patient of concern. Patient and the level of communication creates a potential for patients who may recover Write care ;! You want unit: a nursing model, as autonomous agents ; individuals. Creates a potential for patients to undergo burdensome and expensive treatments that they may not acceptable! ( 1994 ) ‘ Limiting care: is CPR for everyone? ’ different from problems, because have. Up all of the incompetent individual encounter in practice vary across institutions P. ( 1984 ‘. 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