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CRITICAL CARE NURSING:
Ethical & Legal Responsibilities
1Prof. Dr. Ram Sharan Mehta, MSND, CON, BPKIHS
 In law a man is guilty when he
violates the rights of others. In
ethics he is guilty if he only
thinks of doing so.
-Immanuel Kant
Prof. Dr. R S Mehta, BPKIHS 2
Ethical & Legal
Decisions in
Critical Care
Units
Learning Objectives
 Distinguish between ethical and legal
standards.
 Review ethical principles.
 Discuss common ethical dilemmas and
decision.
 Discuss the common legal decision in
critical care units.
Ethical
Standards
• Based on
human
principle of
right & wrong
Legal Standards
• Based on
written law
Ethical Decision
Making
 emerged in the recent years as a
major component of health care
for the critically ill patients.
 refers to the process of
evaluating and choosing among
alternatives in a manner
consistent with ethical principles.
Ethical principles
• Patient’s right to self
determination.Autonomy
• do no harm.Non-maleficent
• promoting goodBeneficence
• the obligation to tell the truth.Veracity
• faithfulness to agreements &
responsibilitiesFidelity
• the fair allocation of medical
resources.Justice
Ethical Dilemmas Experienced by Nurses
Working in Critical Care Units:
 Identified “end-of-life decisions,
Patient care issues and human
rights issues” as the emerging ethical
issues.
 In resolving the dilemmas most of the
participants indicated that they would
report the issues to the physician.
Ethical Decisions
End-of-life Issues
• Palliative Care
• CPR decisions
• Euthanasia
• Withholding & withdrawing treatment
• Futile care
Practical Principles for
Ethical decision making
 Identify source of authority for
decision making.
 Achieve effective communication
with patient and families
Practical Principles for
Ethical decision making
 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.
Recommendations for end-of-life care in
the intensive care unit: A consensus
statement by the American College of
Critical Care Medicine
 Concluded that End-of-life care is
emerging as a comprehensive area of
expertise in the ICU & highlighted the
importance of shared decision
making and the importance of caring
for patients’ families
Palliative 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.
CPR Decisions
 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.
Euthanasia
 Euthanasia, a Greek word meaning
“good death,” is popularly known as
“mercy killing.”
Active euthanasia
Passive euthanasia
Withholding or withdrawal of
life support
 Withholding: never
initiating a treatment
 Withdrawing: to stop a
treatment once started
 Best made after careful
discussion (health care
professional, patient and
family)
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.
Perceptions of “futile care”
among caregivers in intensive
care units
 Respondents felt that futile care was
provided because of family demands, a
lack of timely or skilled communication,
or a lack of consensus among the
treating team.
Legal decisions in critical
care units
Medical documentation
Use of restraints
Declaring Brain death
Passive Euthanasia
Organ donation
Autopsy
Medical Documentation
 Informed consent
 Advanced Directives
 Incident Reports
Informed Consent
 In order to be considered
legally effective, consent to
medical treatment must meet
three tests:
(1)voluntary
(2)adequately informed or
knowing.
(3)given by an individual with
adequate mental capacity
and legal authority.
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.
Incident reports
 Document the occurrence of 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 a potentially or
actually harmful incident or who witnesses
an injury is the one who fills out the
incident form.
Other Important legal
documents
 Consultations & referral slips
 Nurses record
 Treatment and investigation record
 TPR chart, BP monitoring chart, IO
chart/ Progress report
 Operative notes
 Discharge summary
 Death certificate
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
Nurses’ related factors influencing
the use of physical restraint in
critical care units
 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
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 are
coma, absence of brainstem reflexes,
and apnoea.
Passive euthanasia
 Passive euthanasia is legal in India. On 7
March 2011 the Supreme Court of
India legalised passive euthanasia by
means of the withdrawal of life support to
patients in a permanent vegetative state
 In Nepal?
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.
 First brain death donor kidney transplant
was performed on May 2017.
Autopsy
 An 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.
Some Common Concepts:
Prof. Dr. R S Mehta, BPKIHS 32
Patient’s bill of rights
1. Right to considerate & respectful care.
2. Right to information
3. Right to make decisions
4. Right to have advance directive
5. Right to privacy
6. Right to confidentiality
7. Right to review the records
8. Right to proper treatment and referral
9. Right to ask & be informed of the existing business relationship
among hospital , educational institutions, other health care
providers or payers
10. Right to consent to participate in research
11. Right to reasonable continuity of care
12. Right to be informed of hospital policies.
10/14/2019 33
Which cases are medico legal?
 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 attempted suicide
10/14/2019 34
Important legal documents
 Specialist consultations & referral slips
 Nurses record
 Treatment record
 TPR chart, BP monitoring chart, IO chart/ Progress
report
 Operative notes, Anesthetists notes
 Final diagnosis
 Discharge summary & follow up notes/ death
certificate
10/14/2019 35
“4 A’s” and “4 R’s”
A resource developed by the American Association of
Critical-Care Nurses (AACN). The 4 A’s are sequential
steps in raising one’s awareness and committing to
action.
1. Ask – Reflect to become aware of your feelings of moral
distress. Are you and/or team members 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.
10/14/2019 36
 If you are uncertain about taking
action, the 4 R’s can help you to
clarify:
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 and various courses of action?
4. Roadblocks – What are the barriers to taking
action or a particular course of action?
10/14/2019 37
Legal safeguards for nurses
 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
10/14/2019 38
Nursing council act 2052
 A person who carries on the nursing
profession in contravention of Section 20
(Prohibition on carrying on nursing
profession: No person other than a
registered nursing professional shall be
entitled to carry on the nursing
profession, directly or indirectly)shall be
punished with a fine not exceeding Three
Thousand Rupees or with imprisonment for
a term not exceeding Six months or with
both.
10/14/2019 39
Consumer protection act 2054
 A person who commits or cause to commit
any Act in violation of Section 10 (To
mislead consumers by making false or
misleading claim that the consumer goods
or service, to engage in unfair trade
practices in such a manner as to make false
or misleading publicity or advertisements)
shall be punished with imprisonment for a
term not exceeding five years, or with a fine
not exceeding One Hundred Thousand
Rupees or with both.
10/14/2019 40
To produce, sell or supply any of the consumer goods
or services which may cause harm to the health of the
consumers
1 )If there is a threat to life, for a term not exceeding
fourteen years, or with a fine not exceeding Rs 500,000,
or with both.
(2) In case the strength of any organ of the body is likely to
be reduced or lost, with imprisonment for a term not
exceeding ten years, or with a fine not exceeding Rs
500,000, or with both.
(3) In other circumstances, with imprisonment for a term
not exceeding five years, or with a fine not exceeding Rs
300,000, or with both.
10/14/2019 41
“For the implementation of high quality of nursing
practice in the world of latest medical and
technological advances, good knowledge of legal
right is necessary.”
1.5. critical care ethical and legal responsibilities

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1.5. critical care ethical and legal responsibilities

  • 1. CRITICAL CARE NURSING: Ethical & Legal Responsibilities 1Prof. Dr. Ram Sharan Mehta, MSND, CON, BPKIHS
  • 2.  In law a man is guilty when he violates the rights of others. In ethics he is guilty if he only thinks of doing so. -Immanuel Kant Prof. Dr. R S Mehta, BPKIHS 2
  • 3. Ethical & Legal Decisions in Critical Care Units
  • 4. Learning Objectives  Distinguish between ethical and legal standards.  Review ethical principles.  Discuss common ethical dilemmas and decision.  Discuss the common legal decision in critical care units.
  • 5. Ethical Standards • Based on human principle of right & wrong Legal Standards • Based on written law
  • 6. Ethical Decision Making  emerged in the recent years as a major component of health care for the critically ill patients.  refers to the process of evaluating and choosing among alternatives in a manner consistent with ethical principles.
  • 7. Ethical principles • Patient’s right to self determination.Autonomy • do no harm.Non-maleficent • promoting goodBeneficence • the obligation to tell the truth.Veracity • faithfulness to agreements & responsibilitiesFidelity • the fair allocation of medical resources.Justice
  • 8. Ethical Dilemmas Experienced by Nurses Working in Critical Care Units:  Identified “end-of-life decisions, Patient care issues and human rights issues” as the emerging ethical issues.  In resolving the dilemmas most of the participants indicated that they would report the issues to the physician.
  • 9. Ethical Decisions End-of-life Issues • Palliative Care • CPR decisions • Euthanasia • Withholding & withdrawing treatment • Futile care
  • 10. Practical Principles for Ethical decision making  Identify source of authority for decision making.  Achieve effective communication with patient and families
  • 11. Practical Principles for Ethical decision making  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.
  • 12. Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine  Concluded that End-of-life care is emerging as a comprehensive area of expertise in the ICU & highlighted the importance of shared decision making and the importance of caring for patients’ families
  • 13. Palliative 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.
  • 14. CPR Decisions  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.
  • 15. Euthanasia  Euthanasia, a Greek word meaning “good death,” is popularly known as “mercy killing.” Active euthanasia Passive euthanasia
  • 16. Withholding or withdrawal of life support  Withholding: never initiating a treatment  Withdrawing: to stop a treatment once started  Best made after careful discussion (health care professional, patient and family)
  • 17. 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.
  • 18. Perceptions of “futile care” among caregivers in intensive care units  Respondents felt that futile care was provided because of family demands, a lack of timely or skilled communication, or a lack of consensus among the treating team.
  • 19. Legal decisions in critical care units Medical documentation Use of restraints Declaring Brain death Passive Euthanasia Organ donation Autopsy
  • 20. Medical Documentation  Informed consent  Advanced Directives  Incident Reports
  • 21. Informed Consent  In order to be considered legally effective, consent to medical treatment must meet three tests: (1)voluntary (2)adequately informed or knowing. (3)given by an individual with adequate mental capacity and legal authority.
  • 22. 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.
  • 23. Incident reports  Document the occurrence of 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 a potentially or actually harmful incident or who witnesses an injury is the one who fills out the incident form.
  • 24. Other Important legal documents  Consultations & referral slips  Nurses record  Treatment and investigation record  TPR chart, BP monitoring chart, IO chart/ Progress report  Operative notes  Discharge summary  Death certificate
  • 25. 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
  • 26.
  • 27. Nurses’ related factors influencing the use of physical restraint in critical care units  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
  • 28. 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 are coma, absence of brainstem reflexes, and apnoea.
  • 29. Passive euthanasia  Passive euthanasia is legal in India. On 7 March 2011 the Supreme Court of India legalised passive euthanasia by means of the withdrawal of life support to patients in a permanent vegetative state  In Nepal?
  • 30. 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.  First brain death donor kidney transplant was performed on May 2017.
  • 31. Autopsy  An 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.
  • 32. Some Common Concepts: Prof. Dr. R S Mehta, BPKIHS 32
  • 33. Patient’s bill of rights 1. Right to considerate & respectful care. 2. Right to information 3. Right to make decisions 4. Right to have advance directive 5. Right to privacy 6. Right to confidentiality 7. Right to review the records 8. Right to proper treatment and referral 9. Right to ask & be informed of the existing business relationship among hospital , educational institutions, other health care providers or payers 10. Right to consent to participate in research 11. Right to reasonable continuity of care 12. Right to be informed of hospital policies. 10/14/2019 33
  • 34. Which cases are medico legal?  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 attempted suicide 10/14/2019 34
  • 35. Important legal documents  Specialist consultations & referral slips  Nurses record  Treatment record  TPR chart, BP monitoring chart, IO chart/ Progress report  Operative notes, Anesthetists notes  Final diagnosis  Discharge summary & follow up notes/ death certificate 10/14/2019 35
  • 36. “4 A’s” and “4 R’s” A resource developed by the American Association of Critical-Care Nurses (AACN). The 4 A’s are sequential steps in raising one’s awareness and committing to action. 1. Ask – Reflect to become aware of your feelings of moral distress. Are you and/or team members 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. 10/14/2019 36
  • 37.  If you are uncertain about taking action, the 4 R’s can help you to clarify: 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 and various courses of action? 4. Roadblocks – What are the barriers to taking action or a particular course of action? 10/14/2019 37
  • 38. Legal safeguards for nurses  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 10/14/2019 38
  • 39. Nursing council act 2052  A person who carries on the nursing profession in contravention of Section 20 (Prohibition on carrying on nursing profession: No person other than a registered nursing professional shall be entitled to carry on the nursing profession, directly or indirectly)shall be punished with a fine not exceeding Three Thousand Rupees or with imprisonment for a term not exceeding Six months or with both. 10/14/2019 39
  • 40. Consumer protection act 2054  A person who commits or cause to commit any Act in violation of Section 10 (To mislead consumers by making false or misleading claim that the consumer goods or service, to engage in unfair trade practices in such a manner as to make false or misleading publicity or advertisements) shall be punished with imprisonment for a term not exceeding five years, or with a fine not exceeding One Hundred Thousand Rupees or with both. 10/14/2019 40
  • 41. To produce, sell or supply any of the consumer goods or services which may cause harm to the health of the consumers 1 )If there is a threat to life, for a term not exceeding fourteen years, or with a fine not exceeding Rs 500,000, or with both. (2) In case the strength of any organ of the body is likely to be reduced or lost, with imprisonment for a term not exceeding ten years, or with a fine not exceeding Rs 500,000, or with both. (3) In other circumstances, with imprisonment for a term not exceeding five years, or with a fine not exceeding Rs 300,000, or with both. 10/14/2019 41
  • 42. “For the implementation of high quality of nursing practice in the world of latest medical and technological advances, good knowledge of legal right is necessary.”