Ethical and Legal Issues in Critical Care

Nursing
 Ethical Issues
 Critical care nurses face ethical issues every
day
 Informed consent
 Withholding or withdrawal of treatment
 Organ and tissue transplantation
 Confidentiality
 Distribution of health care resources
 Advanced technology for life-sustaining treatments
 Greater frequency in critical care

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 Nurse Advocacy
 Obligation to protect patients
 Serve as patient advocates
 Professional organizations promote ethics and
advocacy
 American Nurses Association
• Code of Ethics for Nurses with Interpretive Statements
 American Association of Critical-Care Nurses
• An Ethic of Care

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 Ethical Dilemma Warning Signs
 Emotionally charged
 Significant change in patient’s condition
 Confusion about facts
 Hesitancy about the correct set of actions
 Deviation from customary practice
 Need for secrecy regarding proposed actions

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 Quick Quiz!
The nurse recognizes which statement as a
potential ethical issue?

A. “The physician explained my mother’s poor prognosis.”

B. “If the breathing machine is helping my mother, why is
the doctor asking me about removing the breathing
tube?”
C. “My mother has designated my brother to make
decisions.”
D. “Can I assist with some of my mother’s care?”

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 Ethical Decision-Making Process
(See Figure 3-1)
1. Assess 3. Develop plan with
Contextual factors patient, surrogate,
Physiological factors family, and team
Personal factors
4. Act on plan
2. Consider options 5. Evaluate plan
 Patient wishes  Short-term
 Burden versus benefit
outcomes
 Ethical principles
 Long-term
 Potential outcomes outcomes
 Apply to other cases

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Figure 3-1. The process of ethical decision making.

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 Ethical Principles
 Autonomy
 Right of self-determination concerning medical care
 Beneficence
 Duty to prevent harm, remove harm, and promote the
good of another person
 Nonmaleficence
 Not to intentionally inflict harm

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 Ethical Principles
(Cont.)
 Justice
 Fair distribution of health care resources
 Veracity
 Truthfulness
 Fidelity
 Faithfulness to commitment
 Confidentiality
 Respect for right to control information

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 Quick Quiz!
The nurse recognizes that this principle guides
health care decisions:

A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Justice

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 Nurse Involvement in Ethical
Decision Making
 Advocacy
 Open communication of patient’s wishes and ethical concerns
 True collaboration with health care team members
 Dilemmas can result in moral distress
 Formal mechanisms (The Joint Commission)
 Bioethics committees
 Ethics consultation
 Opportunities for critical care nurses
 Institutional Ethics Committee membership
 Ethics forums and rounds
 Peer review
 Quality improvement committee membership
 Institutional review boards (research)

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 Quick Quiz!
The nurse recognizes which situation may warrant
an ethics consultation?

A. “We’ve met as a family and agree that we should withdraw life

support.”
B. “My mother has designated her minister as her health care
surrogate.”
C. “We’ve met as a family and want mother to be resuscitated if her
heart stops.”
D. “Mother never got around to completing her living will, so I think
she would want everything done. My brother disagrees.”

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 Duty to Treat
 Nurses are required to care for assigned patients
 Contractual relationship
 Abandonment
 Severing professional relationship when patient is in need of care
 Must ensure that patient care is arranged with another nurse,
including breaks and lunch
 Moral conflict
 A nurse is not required to practice if a situation violates his or her
moral or religious beliefs
 Patient care must be transferred to another to avoid
abandonment
 How should nurses approach situations that result in moral
conflict?

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Selected Issues

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 Elements of Informed Consent
 Competence: ability to understand
 Voluntariness: consent without coercion
 Disclosure of information
 Diagnosis
 Proposed treatment
 Probable outcome
 Benefits and risks
 Alternative treatments
 Prognoses if treatment is not provided

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 Life-Sustaining Treatment
 Factors to consider:
 Constitutional rights
 Quality of life
 Impact of advanced technology
 Medical Futility
 Ordinary versus extraordinary care

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Ordinary Versus Extraordinary Care
 Ordinary care
 Common, noninvasive, and tested treatment
 Nutrition, hydration, antibiotics
 Extraordinary care
 Complex, invasive, experimental treatment
 ACLS, dialysis, unproved therapies

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 Quick Quiz!
Which therapy or treatment often falls between
ordinary and extraordinary care?
A. Intravenous fluids at 100 mL/hr
B. Puréed diet for nutrition
C. Feeding tube for hydration
D. Renal dialysis

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 CPR Issues
 Should a patient be “coded”?
 A do not resuscitate (DNR) order is needed to not
initiate a code
 Advance directives are useful in guiding decision
making PRIOR to code
 Family presence during codes is promoted

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 Life Support
 Definitions
 Withholding: not initiating
 Withdrawal: weaning or removing
 Comfort measures maintained
 Debate views on withholding and withdrawal of
life support

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 Helping Families Make Decisions
About Life Support
 Communicate frequently
 Engage in consistent, honest communication
 Base decisions on patient’s wishes
 Provide psychological support to the family

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 Patient Self-Determination Act
 Patient’s right to initiate advance directive
 Patient’s right to consent to or refuse treatment

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 Advance Directive
 Communication about preferences for
treatments if patient is incapacitated
 Do not resuscitate (DNR)
 Natural death
 Living will
 Treatments desired and what should be withheld
 Durable power of attorney for health care
 Determines who makes decisions
 Health care surrogate or proxy

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 Organ and Tissue Transplantation
 Patients who are brain dead are often
candidates for organ donation
 Brain death criteria
 Everyone has the right to donate organs
 Conflict of patient’s designation versus family
members’ views on donation
 Designated requesters seek consent

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 Critical Thinking Challenge
 What are some examples of situations in which
a nurse might have moral or religious
convictions that would interfere with the duty to
treat?
 What actions are required of the nurse when
conflict exists?

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 Critical Thinking Challenge
(Cont.)
 Discuss
 Who has:
• Living will?
• Durable power of attorney for health care?
 Do your family members know your wishes?
 Identify strategies that can be implemented to
get more people to complete advance directives.

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 Critical Thinking Challenge
(Cont.)
 What are issues related to organ donation?
 What are strategies to increase donation,
especially among ethnic minority populations?
 If you have a signed organ donor card, can your
family members overrule your wishes?

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