This document discusses several ethical dilemmas that arise in intensive care medicine, including issues around changing goals of care, futility of treatment, and quality of life. It outlines key ethical principles like beneficence, non-maleficence, justice, and autonomy. Decision-making approaches like paternalism and determinism are discussed. The document also explores concepts like futility, quality of life, resource allocation, and indicators for high quality end-of-life care. Two scenarios pose ethical dilemmas around prolonged ICU stays and disagreements between medical teams.

1. Ethical Dilemmas in
Intensive Care
Dr. Andrew Ferguson

2. “The primary goals of intensive care
medicine are to help patients survive
acute threats to their lives while
preserving and restoring the quality
of those lives”
Truog R, et al. Critical Care Medicine 2008; 36: 953-963

3. Issues with changing goals of care
Most patients have a deep desire not to be
dead.
Medicine cannot predict the future, and cannot
give patients a precise, reliable prognosis about
when death will come.
If death is the alternative, many patients who
have only a small amount of hope will pay a high
price to continue the struggle”
Truog R, et al. Critical Care Medicine 2008; 36: 953-963

4. FutilityQuality of life
Autonomy
Justice
Beneficence
Non-maleficence
Utility Equity

5. • Beneficence: the physicians’ duty to help
patients whenever possible
• Non-maleficience: the obligation to avoid harm
• Justice: the fair allocation of medical resources
• Autonomy: the patients’ right to self-
determination

6. • Paternalistic decision-making = physician
• Determinative decision-making = shared

7. Underpinning concepts
• Withholding and withdrawing life support are
equivalent
• There is an important distinction between killing
and allowing to die
• The doctrine of “double effect” - ethical rationale
for providing symptom control even when this
may have the foreseen (but not intended)
consequence of hastening death

8. Challenges
• Competing demands for limited resources
• Futility
• Quality of life
• Burnout
• Therapeutic nihilism
• Fatalism

9. What is futility?

10. a medical intervention that had not been useful in the last 100
cases OR interventions that merely preserve permanent
unconsciousness or dependence on intensive medical care
“Treatments should be defined as futile only when they will not
accomplish their intended (physiologic) goal”.
“Treatments that are extremely unlikely to be beneficial, are
extremely costly, or are of uncertain benefit may be considered
inappropriate and hence inadvisable, but should not be labeled
futile”.
Futility

11. What is quality of life?

12. Elements of Quality of Life
Physical Psychological Social

13. Whose life is it anyway?

14. How do we know...?
• Who should be admitted?
• What are the indicators that we shouldn’t admit?
• How much illness is too much?
• When should we say enough is enough?
• How can we be certain?

15. Quality indicators for end-of-life care
• Patient and family-centred decision-making
• Communication with family and patient
• Communication within team
• Continuity of care
• Emotional and practical support for patient/family
• Symptom management and comfort care
• Spiritual support for patient/family
• Emotional/organisational support for ICU clinicians

16. Scenario 1
• Spinal cord injury:
• quadriplegia
• ventilator dependence
• prolonged pressure sore
• difficult access to rehab bed
• Is a prolonged ICU stay appropriate?
• What about other patients rights to care?
• What are you using to inform your decisions?

17. Your thoughts?

18. Scenario 2
• Elderly patient with significant comorbidity
• Profound septic shock and MSOF and no improvement in
48 hours of maximum therapy
• Outlook bleak...discussion with family...patient would not
want treatment that will not get her better....would not
want CPR etc
• Agreement to DNAR and no escalation with clear plan to
withdraw the following day if no MAJOR improvement
(definition given)...family content with plan and
communicated to extended family

19. • Change of consultant the next day
• New consultant gets verbal hand-over of
decision making process and outcome
• New consultant not happy to withdraw
• Family upset and angry with change in plan
• Patient treated aggressively for further 48
hours before withdrawal and death
Scenario 2

20. Your thoughts?