Primarily, it is the treating medical officer who is legally regarded as the only person able to inform the patient about any material risks associated with a clinical therapy or intervention.18. Managing the critically ill patient in many cases represents a provision of supportive, rather than curative, therapies.29, A common ethical dilemma found in critical care is related to the opposing positions of ‘maintaining life at all costs’ and ‘relieving suffering associated with prolonging life ineffectively’. 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. Artificial hydration and … Quality of life is often used as a means of justifying a particular decision about treatment that results in either cessation of life or continued life-sustaining treatment, and it tends to be expressed as if a shared understanding exists. A competent individual has the right to decline or accept healthcare treatment. For those who are not competent and require someone to be appointed to make healthcare decisions on their behalf, there are various agencies such as ‘Guardianship Boards’ or ‘Office of the Public Advocate’ – depending again on the specific jurisdiction – that will appoint such a person. (ed.). ‘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.4 Institutional ‘position statements’ or ‘policies’ are useful to remind patients, laypersons and health professionals that patients do have entitlements and special interests that need to be respected. Patients’ rights are a subcategory of human rights. Related to this issue is that of the human rights of research subjects, as well as of health professionals as researchers in a variety of sociocultural contexts, and the contribution that international human rights instruments can make in the application of the general principles of ethics to research involving human subjects. Some international literature reflects the different ethical reasoning and decision-making frameworks extant between medical staff and nurses. Leavitt, F.J. (1996) ‘Educating nurses for their future role in bioethics’. Every country has its own sources and structures of law. 1990 Mar;2(1):1-13. • For research involving more than minimal risk, an explanation as to whether any compensation, and an explanation as to whether any medical treatments are available, if injury occurs and, if so, what they consist of, or where further information may be obtained. 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). It should also be noted that nurses must seek consent for all procedures that involve ‘doing something’ to a patient (e.g. The nurse justifies public trust and confidence. • Discuss strategies to address moral distress in critical care nursing. This situation particularly arises when the patient is incompetent and is therefore unable to participate in the decision-making process. The legislation varies as to what situations are covered, but some common themes are apparent. 4. In it simplest form, ethics refer to standards that govern behaviours. In some countries, religion informs the law based on scriptures. 3. An autonomous person is an individual capable of deliberation and action about personal goals. (1997) ‘Protocols and emergency nurse practitioners’, Melia, K. (1996) ‘The nursing perspective’, in Pace, A, and McLean, S.A.M. (1993) ‘Commentary on mortality in intensive care patients with respiratory disease: is age important?’. 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. 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. Not affiliated An explanation of whom to contact for answers to pertinent questions about the research and research subjects’ rights, and whom to contact in the event of a research-related injury to the subject. Kendrick, K. and Cubbin, B. Kendrick, K. (1994a) ‘Building bridges: teaching ward-based ethics’. Hence, decisions regarding withdrawal and withholding of life support treatment(s) are not made without substantial consideration by the critical care team. Ethical issues in critical care: a nursing model. A competent individual has the right to decline or accept healthcare treatment. Nurses value environmental ethics and a social, economic and ecologically sustainable environment that promotes health and wellbeing. There are also articles concerning end-of-life care and cardiopulmonary resuscitation. Directors and managers of ICU units have several ethics teaching options. 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. An understanding of the principle of consent is necessary for nurses practising in critical care. Hospitals should provide detailed patient admission information, including information regarding ‘patients’ rights and responsibilities’, that usually include a broad explanation of the consent process within that institution. 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. Medical decisions to withdraw treatment were shown to vary between medical staff and among patients with similar pathologies.43, 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. This person would usually be a spouse, close relative or unpaid carer of the incompetent individual. 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. In the US35–37 and Europe38 the majority of doctors have withheld or withdrawn life-sustaining treatments. • A statement that participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitled, and the subject may discontinue participation at any time without penalty or loss of benefits, to which the subject is otherwise entitled. End-of-life decision making is usually very difficult and traumatic. It should also be noted that nurses must seek consent for all procedures that involve ‘doing something’ to a patient (e.g. With the introduction in the UK of the Human Rights Act21 there is increasing public awareness of individual rights, and in the medical setting people are encouraged to participate actively in decisions regarding their care. (This is different in the case of a person who is legally declared brain dead; see Brain death section. Nurses accept the rights of individuals to make informed choices in relation to their care. Depending on the prevalent culture at any one of these levels, nursing practice may be highly ethical or less ethically justifiable. Discussion: legal and ethical issues in handling and reporting. Safe delivery of those therapies is often the nurse’s responsibility, which is distinct from the medical order issued to commence the treatment. 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. 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). Drought, T.S. Author information: (1)University of Barcelona, Spain annafalco@ub.edu. Common ethical principles that relate to critical care nursing practice are outlined in this chapter, with a description of how they may be applied to practical situations such as clinical decision making, obtaining informed consent and applied research. People may also have a combination of both. b. patient as part of the hospital admission process. 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. • be able to comprehend and retain information, • believe it (i.e. administering an injection), and should be wary of relying on ‘implied’ consent. Ethical Principles• Autonomy• Beneficence• Nonmaleficence• Justice• Veracity• Fidelity 4. 1. 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. 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, Consent to collection, use, disclosure of health information, It is important to distinguish between health information, Application of Ethical Principles in the Care of the Critically Ill. Critical care nurses should maintain awareness of the ethical principles that apply to their clinical practice. when an individual lacks decisional capacity). Penn, K. (1994) ‘Patient advocacy in palliative care’. The Australian and New Zealand Intensive Care Society (ANZICS) recommends an ‘alternative care plan’ (comfort care) be implemented with a focus on dignity and comfort. Research may well be carried out in populations rendered vulnerable because of their low levels of education and literacy, poverty and limited access to health care, and limited research governance. Hence, decisions regarding withdrawal and withholding of life support treatment(s) are not made without substantial consideration by the critical care team.30, 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,31 although the incidence in other critical care areas has not been reported. the level to which basic needs are met, such as avoiding harm, and adequate nutrition and shelter). Rushton, C.H. Allmark, P. and Klarzynski, R. (1992) ‘The case against nurse advocacy’. These are useful records to provide clarity when treatment options require full and frank discussion and consideration, particularly regarding complex, critically ill patients (see Palliative care below). A statement that participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitled, and the subject may discontinue participation at any time without penalty or loss of benefits, to which the subject is otherwise entitled. 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. This right is enshrined in common law in Australia (with state to state differences), and in the Code of Health and Disability Consumers’ Rights in New Zealand (1996).13,20 It is the cornerstone of the legal administration of healthcare treatment. 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 that event, it is likely that withdrawal of treatment will not occur until concordance is reached. One example of a combination document is the Five Wishes advance directive in the US, created by the non-profit organisation Aging with Dignity. Anna Falcó-Pegueroles. These types of situations are referred to as ‘ethical dilemmas’. consider the effects of having or not having the treatment). Many jurisdictions around the world have legislation to cover the case of an adult who is incompetent to give consent. The New Zealand Bill of Rights and the. People may also have a combination of both. Nursing Council of New Zealand Code of Conduct for Nurses, December 200415. 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. 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. Ethical implications of brain death and organ donation that particularly relate to nursing practice are also reviewed. Combinations of these therapies in critical care units are part of everyday management of critically ill patients. A comprehensive understanding of current legal and ethical frameworks facilitates the delivery of appropriate skilled nursing care. 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. (This is different in the case of a person who is legally declared brain dead; see. Current Students; New Nursing Students; Aspiring Students; Vlog; Med Math; iStudentNurse.com | Ethical and Legal Issues in Critical Care. 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). Conditions of scarcity and competition result in the predominant problems associated with distributive justice. Start studying Sole - Chapter 3: Ethical and Legal Issues in Critical Care Nursing. End-of-life decision making is usually very difficult and traumatic. These statements also emphasise to healthcare professionals that their relationships with patients are constrained ethically and are bound by certain associated duties.4 In addition, the World Federation of Critical Care Nurses has published a Position Statement on the rights of the critically ill patient (see Appendix A3). Ideally, an advance directive should be developed by the: a. family, if the patient is in critical condition. Interdisciplinary Education on Discussing End-of-Life Care . c. patient before hospitalization. (eds). 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. 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. Ethics involve principles and rules that guide and justify conduct. For example, codes relevant to nurses have been developed by the Australian Nursing and Midwifery Council (2002). The nurse acts ethically and maintains standards of practice. DOI:10.3912/OJIN.Vol23No01Man01 Key Words:ethical awareness, nursing ethics, ethical sensitivity, moral sensitivity, critical care Ethical awareness involves recognizing the ethical implications of all nursing actions, and is the first step in moral action. A living will is one form of advance directive, leaving instructions for treatment. 5 Top Ethical Issues in Nursing in 2019 Ethics in nursing is fundamental to the integrity of the nursing profession and ensure better patient outcomes. 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. To deny a competent individual autonomy is to treat that person paternalistically. An original nursing model for addressing ethical issues at the bedside is described in this study. be able to comprehend and retain information, believe it (i.e. Regional Health University Proposal for a trial project in Ostergotland (LIV) (1981) Report from the Linkoping Commission on Integrated Health Care Education, Regional Health University: Linkoping. As with formally appointed guardians, the powers of a ‘person responsible’ are limited by statute. 1. (1996) ‘Ethics in the intensive care unit: a need for research’. 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.34 There are marked differences in the ‘foregoing of life-sustaining treatments’ that occur between countries and in the patient level of care variation even within the same country. Much ethically-desirable nursing practice, such as confidentiality, respect for persons and consent, is also legally required. 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. Falcó-Pegueroles, A, Lluch-Canut, T, Guàrdia-Olmos, J. 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. 1. 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. 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. A case study incorporating ethical conflicts demonstrates use of this model. 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). 2. 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. If there is no guardianship order then, strictly speaking, consents for healthcare treatment may be given only by the guardianship authority. Although the nursing role in critical care is pivotal to implementing clinical decisions, it is sometimes unacknowledged and devalued. Teaching Ethics. Another ethical issue in some health care facilities is the population's access to critical care. Nurses respect individual’s needs, values, culture and vulnerability in the provision of nursing care. In situations where there is not enough of a resource to be equally distributed, often guidelines or policies (e.g. The withholding and withdrawing of therapies is considered passive euthanasia and is legal and accepted practice in terminally-ill ICU patients in most of Europe, however in parts of Europe, life-sustaining treatments are withheld but not withdrawn as the withdrawal of therapies leading to death is considered illegal and unethical. Obtaining consent is part of the overall duty of care. Critical care nurses need to be aware of the relevant policies and procedures to have an understanding of their individual obligations and responsibilities. (2)University of Barcelona, Spain. The lack of planning may produce morbidity and mortality that could otherwise have been prevented, thus creating a fundamental duty to … 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. The thrust of this chapter is to explore research findings about issues that cause ethical concern for critical care nurses in Europe. 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. An autonomous person is an individual capable of deliberation and action about personal goals. Describe “best practices” that protect your license and position, influence quality of care and reduce risk. Söderberg, A. and Norberg, A. 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. 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. However, the decision-making process certainly must involve broad, detailed and documented consultation with family and team members. Individuals should be treated as autonomous agents; and individuals with diminished autonomy are entitled to protection. Capacity fluctuates with both time and the complexity of the decision being made; thus, sound decisions require careful assessment of individual patients. 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. Development process and initial validation of the Ethical Conflict in Nursing Questionnaire-Critical Care Version. Considerable debate exists regarding ICU access/admission criteria, that may vary across institutions. Advance directives can be signed only by a competent person (before the onset of incompetence), and can be either instructional (e.g. Substituted judgement is relatively informal, in Oden, G ethical issues in critical care nursing be someone involved. 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