ST. MARY’S COLLEGE OF TAGUM, INC.

NURSING PROGRAM

LEARNING
NCM 118 - CARE OF CLIENTS WITH LIFE-THREATENING CONDITIONS,
ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY

MODULE
SITUATION
BSN4

Lesson 3: Ethico-Legal Considerations

in the Critical Care

Prepared by:
JOSEFINA S. BALOTE,RN,MN
 Module 1 – Lesson 1

Timothy 5:8 “Then your

light will break forth like
the dawn, and your
healing will quickly
appear; then your
righteousness will go
before you and the glory
of the Lord will be your
rear guard.”

2
 Module 1 – Lesson 1

Ignacian Core/ Related

Values:,
Excellence; service, Faith

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 Module 1 – Lesson 1

Learning Outcomes
At the end of the lesson the students can:

1. Discuss the ethico-Legal Responsibilities in the

Critical Care Unit Nursing
 
2. With a given scenario formulate a plan of action to
address the nursing needs and problems of the client.

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 Introduction

This unit introduces the ethico-legal considerations in

critical care nursing

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 Learning Contents

Ethico-Legal Considerations in the Critical

Care
 
Patient Safety Guidelines in Critical Care
Ethical and Legal considerations in the Care of
the Critically Ill
Scope of Nursing Practice based on R.A. 9173
Patient’s Bill of Rights and Obligations:
Unconscious Client

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 Learning Contents

Ethico-Legal Considerations in the Critical

Care
 
Patient Safety Guidelines in Critical Care
Ethical and Legal considerations in the Care of
the Critically Ill
Scope of Nursing Practice based on R.A. 9173
Patient’s Bill of Rights and Obligations:
Unconscious Client

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

ETHICAL PRINCIPLES
Autonomy – Patient’s right to self determination
Non-maleficent – do no harm
Beneficence – Promoting good
Veracity – the obligation to tell the truth
Fidelity – faithfulness to agreements and
responsibilities
Justice – the fair allocation of medical resources
 

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

ETHICAL DILEMMAS EXPERIENCED BY

NURSES WORKING IN CRITICAL CARE UNITS
Identified “end-of-life decisions,
Patient care issues and
Human rights issues

How to resolve the dilemma?

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

PRACTICAL PRINCIPLES FOR ETHICAL

DECISION MAKING

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

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

RECOMMENDATIONS FOR END-OF-LIFE

CARE IN ICU : A CONSENSUS STATEMENT BY
THE AMERICAN COLLEGE OF CRITICAL CARE
MEDICINE

Concluded that End-of-life care is emerging

comprehensive area of expertise in the ICU and
highlighted the importance of shared decision
making and the importance of caring for patients’
families

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

PALLATIVE CARE
 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

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

CPR DESISIONS
 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.

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

EUTHANASIA
Is a Greek word meaning “good death”, is
popularly known as “mercy killing”

Active
Passive

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

WITHHOLDING OR WITHDRAWAL OF LIFE

SUPPORT
WITHHOLDING: never initiating a treatment
WITHDRAWING: to stop a tratment nce started.
Best made after careful discussion (health care
professional, patient and family)

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

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

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

PERCEPTIONS OF “FUTILE CARE” AMONG

CAREGIVERS IN ICU

Respondents felt that futile care was provided

because of family demands, a lack of
consensus among treating team

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

LEGAL DECISIONS IN CRITICAL CARE UNITS

Medical Documentation
Use of Restraints
Declaring Brain Death
Passive Euthanasia
Organ Donation
Autopsy

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

MEDICAL DOCUMENTATION
 Informed Consent
Advanced Directives
Incident Reports

IF YOU DIDN’T DOCUMENT IT, YOU

DIDN’T DO IT

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

ADVANCE DIRECTIVES
 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.

IF YOU DIDN’T DOCUMENT IT, YOU

DIDN’T DO IT

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

INCIDENT REPORTS
 document the occurrence bof 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 potentially or

actually harmful incident or who witnesses an
injury is the one who fills out the incident
form.

IF YOU DIDN’T DOCUMENT IT, YOU

DIDN’T DO IT

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

OTHER IMPORTANT LEGAL DOCUMENTS

 consultations and referral slips
Nurses record
Treatment and investigation record
TPR Chart, BP monitoring chart, I&O,
Progress Report
Operative Notes, Anesthesia notes
Final Diagnosis
Discharge Summary and follow up notes
Death Certificate

WRITE IT ALL DOWN!

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

USE OF RESTRAINTS
• 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

WRITE IT ALL DOWN!

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

NURSES’ RELATED FACTORS INFLUENCING

THE USE OF PHYSICAL RESTRAINT IN ICU
 It can be concluded that those older nurses
and those with higher qualification and years
of experience have better performance than
others

Nurses’ knowledge and performance are in

need for improvement

WRITE IT ALL DOWN!

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

DECLARING BRAIN DEATH

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

3 essential findings in brain death:

A. coma
B. absence of brainstem reflexes
C. apnoea

WRITE IT ALL DOWN!

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

PASSIVE EUTHANASIA
 it is legal in India. On 7th March 2011 the
Supreme Court Of India legalized passive
euthanasia by means of withdrawal of life
support to patients in permanent vegetative
state

WRITE IT ALL DOWN!

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

ORGAN DONATION DECISION

 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 Transplant Act, 2072 has also been
passed in Nepal ( Philippines: epublic Act
No. 7170 of 1991, Amended by Republic Act No. 7885

1st brain death donor kidney transplant

was performed on May 2017

POS-982 A CASE REPORT OF THE FIRST

DECEASED ORGAN DONOR IN THE PHILIPPINES
DURING THE COVID-19 PANDEMIC

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

AUTOPSY
 or postmortem examination is an
examination of the body after death

The law describes under what circumstances

an autopsy must be performed, for example,
all Medico-Legal Cases should undergo
autopsy

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

PATIENT’S BILL OF RIGHTS

1. Right to considerate
Right to information
Right to make decisions
Right to mhave advance directives
Right to privacy
Right to confidentiality
Right to mreview the records
Right to proper treatment and referral
Right to ask and be informed of the existing
business relationship among hospital,
educational institutions, other health care
providers or payers
Right to consent to participate in research
Right to reasonable continuity of care
Right to be informed of hospital policies

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

MEDICO LEGAL CASES

All cases of injuries
All cases of burn
Alleged cases of assault
All cases of suspected or evident of
poisoning or intoxication
Vases referred from court
Cases of suspected or evident of abortion
Cases of unconscious/comatose where its
cause is not natural or not clear
Cases brought dead/ dead on arrival/ sudden
unexpected death
Cases of suspected self inflicted injuries or
attempted suicide

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 Learning Contents

Ethico-Legal
Considerations in the
4 “A”s
Critical and 4 “R”s (American Asso of Critical-
Care
care Nurses (AACN)

4”A”s – sequential steps in raising one’s

awareness and committing to action
1. ASK – reflect to become aware of your
feelings of moral distress. “ Am I experiencing
moral distress?
2. AFFIRM – validate your feelings with others
and make a commitment to address moral
distress
3. ASSESS – assess the degree of your
distress and your readiness to act
4. ACT – make a personal and professional
action plan. Carry it out and act to sustain the
change

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

4 “R”s (American Asso of Critical-care

Nurses (AACN) – helps clarify your
uncertainties
1.RELEVANCE – in what ways and to who is
the issue important?
2.RISKS – what are the risks of taking action
and of NOT taking action?
3.REWARDS – what benefits can be obtained
by acting various courses of action/
4.ROADBLOCKS – what are the barriers to
taking action or a particular course of action?

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

LEGAL SAFEGUARDS FOR NURSES

1. Informed consent
Contract
Collective bargaining
Competence practice
Licensure
Patient Education
Executing Physician’s Order
Documentation
Professional Liability Insurance
Good Samaritan Law
Adequate staffing
Patient’s Bill of RIghts

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SYNTHESIS

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 Learning Contents

Ethico-Legal
Considerations in the
Critical Care

ETHICAL DILEMMAS EXPERIENCED BY

NURSES WORKING IN CRITICAL CARE UNITS

IDENTIFIED “END-OF-LIFE DECISIONS,

 palliative care
CPR decisions
Euthanasia
Withholding and withdrawing treatment
Futile care

How to resolve the dilemma?

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 Learning Contents

Patient Autonomy,

Three elements to the psychological capacity of

autonomy: 
A. agency,
B. independence, and
C. rationality.

Agency is awareness of oneself as having desires

and intentions and of acting on them.

Independence refers to the actual state of being

free from other people's influence or control

Rationality refers to the act of determination

of the self by itsef

 In acute care, the patient has decisional and

executive autonomy

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 Learning Contents

Patient Autonomy,

Adherence to complex treatments commonly

breaks down when patients have functional,
educational, and cognitive barriers that impair
their capacity to plan, sequence, and carry out
tasks associated with chronic care.

in acute-care paradigm the patient has the role

in medical decisions. The adult patient is
presumed to have adequate capacity to
understand and make decisions, i.e., to
possess decisional autonomy, and therefore is
presumed to have the capacity to participate in
decisions about his or her medical care

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 Learning Contents

Patient Autonomy

The ethical principle of respect for autonomy

requires that the patient with decisional autonomy
be accorded authority over what will or will not be
done regarding his or her medical care (
Beauchamp and Childress 2001)

From the perspective of decisional autonomy,

behaviors or outcomes that are incongruent with
the treatment plan are interpreted by clinicians as
either an autonomous refusal of the physician’s
recommendations or the result of significant
impairments in decisional autonomy that need to
be assessed and responsibly managed.

Some patients with chronic conditions may

articulate understanding of the management plan
and appear non-adherent when actually they are
unable to implement the steps necessary to meet
the treatment objectives. 

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 ASSESSMENT 

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