infection, pneumothorax on insertion). 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. Patients’ rights are a subcategory of human rights. To deny a competent individual autonomy is to treat that person paternalistically. In general, nurses focus on aspects such as patient dignity, comfort and respect for patients’ wishes, while medical staff tend to focus on patients’ rights, justice and quality of life.47 Involvement of the patient (where possible) and family in decision making is an important aspect of matching the care provided with preferences, expectations, values and circumstances (see Figure 5.1).48, 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. This person would usually be a spouse, close relative or unpaid carer of the incompetent individual. The nurse acts ethically and maintains standards of practice. This service is more advanced with JavaScript available, Ethical Issues in Nursing and Midwifery Practice Publications and Materials of the Bioethics Research Library. 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. One example of how statute law is applied in practice regards consent for life-sustaining measures; the Consent to Medical Treatment and Palliative Care Act 1995 (SA)11 states that: … in the absence of an express direction by the patient or the patient’s representative to the contrary, [the doctor is] under no duty to use, or to continue to use, life sustaining measures … (S17 (2)). Nurses promote and uphold the provision of quality nursing care for all people. 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. Chapter 7- Ethical Issues in Critical Care Nursing My Nursing Test Banks . A medical agent is someone chosen by an individual (e.g. Ricoeur, P. (1984) ‘The model of the text: meaningful action considered as text’. 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. 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. In recent decades, research in the biomedical sciences has been increasingly located in settings outside of the global north. 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. Another ethical issue in some health care facilities is the population's access to critical care. Abstract. 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. 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. 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. These articles deal with the many ethical issues critical care nurses deal with every day. Patients’ rights are a subcategory of human rights. The best interests principle is a guiding principle for decision making in health care, and is defined as acting in a way that best promotes the good of the individual. 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. Making a substituted judgement is relatively informal, in the sense that the patient usually has not formally appointed the proxy decision maker. Other related ethical concepts include integrity, best interests, informed consent and advance directives. Describe “best practices” that protect your license and position, influence quality of care and reduce risk. The nurse justifies public trust and confidence. The terms ‘legislation’ and ‘law’ are used to refer generically to statutes, regulation and other legal instruments that may be the forms of law used in a particular country. The nurse acts ethically and maintains standards of practice. In addition, individual preferences may change over time. 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. 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. 5. Dilemmas are different from problems, because problems have potential solutions.5. 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. 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. Consent in human research is guided by a variety of different documents. However, the decision-making process certainly must involve broad, detailed and documented consultation with family and team members. A competent individual has the right to decline or accept healthcare treatment. In health care, egalitarian theories generally propose that people be provided with an equal distribution of particular goods or services. The need to support critical care nurses, by mentoring for example, is very important in terms of developing moral knowledge and competence in the critical care context.3, Australian Nursing and Midwifery Council Code of Ethics for Nurses in Australia, June 200261. Teresa Lluch-Canut. Resource limitations can potentially be seen to negatively affect distributive justice if decisions about access are influenced by economic factors, as distinct from clinical need.9, Ethics are quite distinct from legal law, although these do overlap in important ways. The guidelines from the Council for International Organizations of Medical Sciences (CIOMS) – a body established jointly by WHO and UNESCO – take the position that research involving human subjects must not violate any universally applicable ethical standards, but acknowledge that, in superficial aspects, the application of the ethical principles, e.g. Kendrick, K. (1993) ‘Understanding ethics in nursing practice’. Managing the critically ill patient in many cases represents a provision of supportive, rather than curative, therapies. Kendrick, K. and Cubbin, B. 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. Social and economic inequalities are important variables in understanding the practical difficulties in obtaining informed consent. 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’. b. patient as part of the hospital admission process. Nurses appear at times unable to influence the decision-making process.46, Some international literature reflects the different ethical reasoning and decision-making frameworks extant between medical staff and nurses. Although the nursing role in critical care is pivotal to implementing clinical decisions, it is sometimes unacknowledged and devalued. (eds). 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. Given the complexity of contemporary healthcare environments, it is vital that nurses are a… In Australia, when active treatment is withdrawn or withheld, legally the same principles apply. Others are incorporated in broader issues, such as brain death and organ donation. 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. An original nursing model for addressing ethical issues at the bedside is described in this study. After the physician leaves, the patient, who is visibly shaken, asks the nurse, Couldnt the doctor be wrong? Comparisons between the experience of critical care nurses in Sweden and the United Kingdom will be made for the simple reason that these are the only two European countries that have, to date, published research papers related to the way that nurses deal with, or feel about, the moral dimensions of critical care practice. Many clinical scenarios invite ethical reflection and raise questions about health professionals’ decision making and behaviour, as distinct from specific diagnostic or technical questions. (1982) ‘The role of caring in nursing ethics’, in Oden, G. Interdisciplinary Education on Discussing End-of-Life Care . Buy Membership for Critical Care Medicine Category to continue reading. Evidence-based protocols exist for caregivers/nurses for both the safe insertion of a CVC and subsequent care, so as to minimise possible harms to the patient. 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. 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. © 2020 Springer Nature Switzerland AG. Individuals should be treated as autonomous agents; and individuals with diminished autonomy are entitled to protection. Anna Falcó-Pegueroles . Individuals should be treated as autonomous agents; and individuals with diminished autonomy are entitled to protection. The medical agent should be someone not involved in a professional capacity in the delivery of the related health care. 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. A competent individual has the right to decline or accept healthcare treatment. Advance directives were created in response to increasing medical technology.53,54. Acts such as the. 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.4 Difficulties arise in ethical decision making where no consensus has developed or where all the alternatives in a given situation have specific drawbacks. 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. 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. Managing a critical care unit can present many challenges for those whose roles have been only as clinicians. Bioethics Research Library of the Kennedy Institute of Ethics. The majority of the community and doctors favour active life-ending procedures for terminally-ill patients. 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. Justice may be defined as fair, equitable and appropriate treatment in light of what is due or owed to an individual. 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. Kendrick, K. (1994a) ‘Building bridges: teaching ward-based ethics’. In Australia, when active treatment is withdrawn or withheld, legally the same principles apply. Ethical conflict in critical care nursing: Correlation between exposure and types. Combinations of these therapies in critical care units are part of everyday management of critically ill patients. Teaching Ethics. Nurses in all settings and roles are bound by the ANA’s nursing code of ethics, which deals with various areas of patient care and provides guidance in handling the top ethical issues in nursing today, such as the five discussed below. To respect autonomy is to give weight to autonomous persons’ considered opinions and choices, while refraining from obstructing their actions unless these are clearly detrimental to others or themselves. 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. Not logged in A living will is one form of advance directive, leaving instructions for treatment. To establish that trust you must respect patients’ autonomy – their right to decide whether or not to undergo any medical intervention … [They] must be given sufficient information, in a way that they can understand, in order to enable them to make informed decisions about their care.24, In many countries, if patients believe that clinicians have abused their right to make informed choices about their care, they can pursue a remedy in the civil courts for having been deliberately touched without their consent (battery) or for having received insufficient information about risks (negligence). 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. (This requirement will be discussed in detail in the section below on decision making.). How to Write Care Plans; Nursing Diagnoses; Students. 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. Often, quality of life is considered to consist of both subjective and objective components, based on the understanding that a person’s wellbeing is partly related to both aspects; therefore, in any overall account of the quality of life of a person, consideration is given to both independent needs and personal preferences.9 Subjective components refer to the experience of personal satisfaction or happiness, or the attainment of personal informed desires or preferences. (1986) ‘Do-Not-Resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact’?. Chapter 3: Ethical and Legal Issues in Critical Care Nursing Test Bank MULTIPLE CHOICE 1. and Sibbald, W.J. )34, In the Ethicus study of 4248 patients who died or had limitations of treatments in 37 ICUs in 17 European countries, life support was limited in 73% of patients. 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. 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. One of the most effective ways of teaching nurses and doctors how to handle ethical … BioethicsLine: 1972-1999 Each of these types of consent has differing requirements. Brown, C. (1990) ‘Limiting care: is CPR for everyone?’. Nurses accept the rights of individuals to make informed choices in relation to their care. Acts such as the Consent to Medical Treatment and Palliative Care Act 1995 (SA) exist to facilitate choice in healthcare treatment that individuals may wish to have or refuse when they are unable to make their wishes known because of an illness.11, A substituted judgement is where an ‘appropriate surrogate attempts to determine what the patient would have wanted in his/her present circumstances’.50 The person making the decision should therefore attempt to utilise the values and preferences of the patient, implying that the proxy decision maker would need an in-depth knowledge of the patient’s values to do so. 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. This situation particularly arises when the patient is incompetent and is therefore unable to participate in the decision-making process. Examine medical malpractice cases and the impact on the nurse and the various roles in the acute, long term care & outpatient setting. Many of these guidance documents emphasize the need to protect the public and minimize harm. Levine, M.E. • List steps for making ethical decisions. Patients have cognitive and emotional limitations in understanding clinical information. administering an injection), and should be wary of relying on ‘implied’ consent. 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. 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. Is it really that bad? Justice may be defined as fair, equitable and appropriate treatment in light of what is due or owed to an individual. Resource limitations can potentially be seen to negatively affect distributive justice if decisions about access are influenced by economic factors, as distinct from clinical need. What may be adopted legally and ethically or morally in one country may not be acceptable in another. 3. 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. In the Ethicus study of 4248 patients who died or had limitations of treatments in 37 ICUs in 17 European countries, life support was limited in 73% of patients. 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. Introduction: Nurses face many legal and ethical issues while providing patient care and it is essential to understand the law and the way it affects the nursing practice. 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. In the US35–37 and Europe38 the majority of doctors have withheld or withdrawn life-sustaining treatments. Critical care nurses face ethical issues on a daily basis, whether involving professional ethics or helping a patient or family sort out their own ethical issues. and Sibbald, W.J. The New Zealand Bill of Rights and the. when a doctor makes a decision to cease life-sustaining treatment for a particular patient). 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. It is important to distinguish between health information use (internal to an organisation) and disclosure (external dissemination)19 (see also responsible practices in Ethics in research section later in this chapter). New Zealand and most states of Australia have an Act that allows for the appointment of a person to hold enduring power of attorney. Bertolini, C.L. Söderberg, A. and Norberg, A. • 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. Advance directives can be signed only by a competent person (before the onset of incompetence), and can be either instructional (e.g. One example of a combination document is the Five Wishes advance directive in the US, created by the non-profit organisation Aging with Dignity. The nurse complies with legislated requirements. This principle is clearly articulated by the General Medical Council in the UK with the following statement: Successful relationships between doctors and patients depend on trust. 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. Use the quiz and worksheet to check your knowledge of these issues as well as some medical terms. Nursing codes of ethics incorporate such an understanding of patient’s rights. 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.4. 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. (1997) ‘Protocols and emergency nurse practitioners’, Melia, K. (1996) ‘The nursing perspective’, in Pace, A, and McLean, S.A.M. Anna Falcó-Pegueroles. The physician has just told a patient that he has stage 4 lung cancer and likely has only months to live. Some believe that the present debates about the relative importance of generic and specific consent (particularly in the use of human tissues for research and in secondary studies) do not address this issue squarely, believing that since the point of consent procedures is to limit deception and coercion, they should be designed to give patients and others control over the amount of information they receive and the opportunity to rescind consent already given.22 There is a professional, legal and moral consensus about the clinical duty to obtain informed consent. consider the effects of having or not having the treatment). Allmark, P. and Klarzynski, R. (1992) ‘The case against nurse advocacy’. Development process and initial validation of the Ethical Conflict in Nursing Questionnaire-Critical Care Version. Discussion: legal and ethical issues in handling and reporting. Although it is possible to have a number of medical agents, only one may act for an individual at one time. Author information: (1)University of Barcelona, Spain annafalco@ub.edu. 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. As with formally appointed guardians, the powers of a ‘person responsible’ are limited by statute.19. 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. The lack of planning may produce morbidity and mortality that could otherwise have been prevented, thus creating a fundamental duty to … (1989) ‘Ration or rescue: the elderly person in critical care’, Lindseth, A. (1978) ‘A contrary view of the nurse as patient advocate’, Adshead, G. and Dickenson, D. (1993) ‘Why do doctors and nurses disagree?’, in Dickensen, D. and Johnson, M. (eds). The ANA Code for Nurses requires ethical behavior from all practitioners of nursing. Unable to display preview. Visibly shaken, asks the nurse acts ethically and maintains standards of.. Their clinical practice your knowledge of these guidance documents emphasize the need to the... 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