Dr.

Jayesh Patidar
PhD., M.Sc. Nursing, MBA Asst. Professor Joitiba College of Nursing, Bhandu.

 Ethics have always been an integral part of nursing. Nurses at all levels/areas of practices experience a range of ethical issues during the course of their dayto-day work. Critical care has come to be associated with hightech, aggressive & often risk-filled medical care. The critical care nurse are often confronted with ethical & legal dilemmas related to various ethical principles & it has increased dramatically since the early 1990s. Many dilemmas are byproducts of advanced medical technologies & therapies developed over the past several decades.

Ethical Principles
Autonomy Beneficence Nonmaleficence Justice Veracity Fidelity

Legal and Ethical Issues Informed Consent

Consent problems arises because patients experiencing acute, life threatening illness that interfere with their ability to make decisions on treatment/ participation in clinical research. The informed consent is based on the principle of autonomy. Consent denotes voluntary agreement, permission or compliance.

Legal and Ethical Issues Informed Legal and Ethical Issues Informed Consent Consent
It implies to permission by the patient to perform an act on his body either for diagnosis or therapeutic procedure. The four elements of consent are; voluntariness capacity knowledge Decision making

Type of consent
1. Implied Consent

2. Expressed consent: (verbal written)

Points to be considered in consent

Consent must be given voluntarily If patient is not mentally capable (critical patients) informed consent should be obtained from surrogate or legal next of kin. It should be given by a person of sound mind & above the age of 18 years. Requires the disclosure of basic information considered necessary for decision making Patients providing consent should be free from pain & depression.

 Consent obtained from a minor Consent given under fear, fraud or misrepresentation Consent obtained from the person who is not fit Consent obtained in language not understood by the person Consent obtained from person under sedation, intoxication or semiconscious Consent obtained without providing adequate information on the possible risks are invalid under law.

MEDICO LEGAL CASE

A medico legal case is any case where the discipline of medicine comes to help the legal fraternity in its discharge of duties. Interface of medicine & law is multi dimensional & can be quite complex & perplexing. Health care professionals have to be very cautious in dealing with the medico legal cases.

MEDICO LEGAL CASE

Request of the patient or relatives or friend for not registering the case as medico legal should not be accepted. The MLC should be registered as soon as physician suspects foul play or case brought several days after the incident. The MLC is received in hospital by; any case brought by police for the purpose of examination & reporting & any case referred for expert management & advice.

Following Cases Should be Considered As MLC& to be Intimate To The Police Regarding Such Cases,
All cases of injuries All cases of burn Alleged cases of assault All cases of suspected or evident of poisoning or intoxication Case referred from court

 Cases of suspected or evident criminal abortion Cases of unconscious/comatose where its cause is not natural or not clear Cases brought dead/dead on arrival/sudden unexpected death etc Cases of suspected self inflicted injuries or at tempted suicide The important considerations in MLC are notification to police, collection & preservation of samples, recording of dying declaration etc.

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MEDICAL DOCUMENTATION
The proper medical documentation is legal necessity. A good record should be correct, clear, comprehensive, chronological & contemporaneous. It is the fact that good records are indispensible for proper care & treatment of patients. Consent from patients before carrying out any procedure is mandatory legal, ethical & moral requirement. Similarly the document once prepared has also to be preserved for specified period of time (3 years from the date of commencement of treatment).

MEDICAL DOCUMENTATION
If any request is made for medical records either by patient/authorized attendant/legal authorities, the documents shall be issued within period of 72 hours & refusal to do so would be misconduct. The following medical documents are almost important as for as legalities are concerned: specialist consultations & referral slips, nurses record, treatment record, TPR chart, BP monitoring chart, IO chart, operative notes, anesthetists notes, progress report, final diagnosis, discharge summary & follow up notes etc. as for as medical legal issues are concerned e.g. death certificate, medico legal reports, medico legal investigation reports, all are of immense important & have to be very specific.

USE OF RESTRAINTS
Restraints are intervention that limits a persons freedom to move. It can be physical or chemical. Researcher reported that the use of physical restraint can lead to: skin trauma, muscular atrophy, nosocomial infection, constipation, incontinence, limb injury, contractures, depression, anger, decline in functional & cognitive state & increasing agitation.

USE OF RESTRAINTS
Because restraints limit movement they also limit autonomy. Considering the physical, psychological & ethical aspects of physical restraint (risks & benefits), it is advocated that such is only used when all other methods of managing the problem have failed, employed with caution & as a last resort & use least restrictive method possible.

DECISIONS REGARDING LIFE SUSTAINING TREATMENT

Usually there are two levels of treatment to consider is: ordinary care (non invasive & treatments like providing nutrition, hydration & antibiotic therapy) & extraordinary care (complex, invasive & experimental treatments like CPR, advanced life support, dialysis & other therapies). However the ethicists believe that any treatment can become extraordinary whenever the patient decides that the burdens outweigh the benefits.

1. Cardio pulmonary resuscitation decisions

Resuscitation efforts are used to reverse the clinical sign of death (loss of spontaneous respiration, loss of cardiac function & unconsciousness). Ethical questions arise on use of CPR & emergency cardiac care. In what situations should resuscitation efforts be used? How long should efforts continue?

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A generally accepted position is that resuscitation should cease if the physician determines the efforts to be futile or hopeless. According to AHA 2000 health care providers may stop CPR when 30 minutes (adult/child) or 15 minutes (newborn) of advanced life support have been attempted without restoration of heart rate & breathing. The Do Not Resuscitate (DNR) order is still not documented legal practice in India. It is a verbal communication between the clinician & the patients relative or caregiver.

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The autonomy of the patient also remains a weak concept. The law is silent or ambiguous on most issues related to end-of-life care. The financial status of the patient appears to be the deciding factor. In most cases health-care expenses are entirely borne either by the patient or by the patients relative Withholding or stopping resuscitation efforts is ethically & legally appropriate if the patient/surrogate has previously made his preferences known through advanced directives.

2. Withholding or withdrawal of life support

Withholding refers to never initiating a treatment, whereas withdrawing refers to stopping a treatment once started. The distinction between not starting a treatment & stopping it is not itself of ethical significance; what is whether the decision is consistent with the patients interests & preferences.

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Ending treatment for sound moral reasons does not violate professional obligations. Health care professionals may find it emotionally more difficult to withdraw a treatment than to withhold it. On the other hand, it is often important to start a treatment to evaluate whether it works, until a diagnosis is confirmed. It is better to start the treatment & later stop if it is ineffective.

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Decisions about treatment at the end of life are often difficult & best made after careful discussions between the health care professional & the patient (or surrogate). The nurse ensures that the patient/surrogate understands the information by clarifying technical terms & helping the patient weigh treatment options. The patient then considers his or her own values & wishes in the context of prognoses & realistic options. The final decision reflection the patients wishes should be supported by the nurse & other members of the health care team. The nurse is morally permitted to refuse to participate in withholding or withdrawing treatment from the patient as stated in section 5.4 of the Code of Ethics.

Points to be considered
Withdrawal of life support is indicated if the patient has Glasgow coma score is less than 5, absence of pupil & motor response 3 days after arrest. Communicate frequently throughout the critical care stay, not just when death is imminent. Provide consistent, honest information. Keep the discussion on withholding/withdrawing life support based on patient wishes & the burden versus benefits of the various options

Points to be considered
Recognize that the patient & family are anticipatory grieving & provide support. Most decisions regarding withdrawal/ withholding of life support are not made in courts. It made based on open communication with patient, family & surrogate as appropriate.

 Despite the success there is severe shortage of organs to meet the demand. Potential donor may agree to donate organs/tissues at any time by signing a donor card, but final consent for donation by the patient, family or surrogate is needed before transplantation team harvest the organ. The removal of organs can be accomplished without causing significant harm to living donor or organ removal are performed only in donor who meet the legal definition of brain death. Everyone has the right to donate their organ/tissues.

 The important ethical principles useful in decision making on transplantation include respect for persons, autonomy, beneficence, Nonmaleficence, justice & fidelity. Critical care nurses are in a position to act as the link between potential organ donor & organ transplant recipients & point out the need for critical care nurses to learn the process of identifying potential donors. Cost versus outcome an ethical issue? The cost of intensive care treatment is very expensive & time consuming. There is much debate today in both the nursing literature & popular press about whether the outcomes from intensive care treatment off set the high cost of prolonging life using technology & scientific knowhow

ETHICAL ISSUES OF MOST CONCERN

The five most frequently cited ethical issues reported by the nurse surveyed were: Protecting patients rights & human dignity Providing care with possible risk to your health (eg. TB, HIV, violence) Respecting/not respecting informed consent to treatment Staffing patterns that limit patient access to nursing care Use/non use of physical/chemical restraints

ETHICAL ISSUES OF MOST CONCERN

A combined analysis of reports revealed the following as being the most personally disturbing issues faced by the nurses surveyed: Staffing patterns that limited patient access to nursing care Prolonging the dying process with inappropriate measures Working with an unethical/incompetent/impaired colleague Providing care with possible health risk Not considering a patients quality of life

WAYS TO RESOLVE ETHICAL PROBLEMS IN CRITICAL CARE SETTING

1. Gather the relevant facts & identify the decision maker(s) & the stakeholders. 2. Identify the ethical problem(s). Involve others in the process & use consultation resources as appropriate. 3. Analyze the problem using ethical guidance & resources. 4. Deliberate about the action alternatives in light of guidance; choose one & justify the choice. 5. Evaluate & reflect.

 The ethical & legal responsibility of nurse working in critical care areas has increased since 1990s. Nurses must maintain & continually update their knowledge base & clinical competence. Failure to do so could not only cause harm to patients but could also put nurses & their employer at risk for allegations & professional negligence. As a registered nurse working within the health care industry it is important to consider all sides of the ethical debate & to always act within the law & with the best interests of the client in mind.