Lecture 4 - Ethical & Legal Issues in Critical Cate Setup (1).pptx

• 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 day-to-day work.
• Critical care has come to be associated with high-tech,
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.
14-Mar-24 Dennis Joe - BScN | RN

E t h i c a l P r i n c i p l e s
 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
It implies to permission by the patient to perform an act
on his body either for diagnosis or therapeutic
procedure.
The FOURElements of Consent
Voluntariness
Capacity
Knowledge
Decision making
Legal and Ethical Issues
Informed Consent

Type of Consent
1. Implied Consent
2. ExpressedConsent(verbal written)

Points to be Considered in Consent
• Consent must be given voluntarily
• If patient is not mentally capable 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.

J
• 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

• 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

MEDICO LEGAL CASE
• Requests by the patient or relatives or friend
not to register the case as medico legal should
not be accepted.
• Should be registered as soon as physiciansuspects
foul playorcase brought several days after the
incident.
• The MLC is received in hospital by;
o Any case brought by police for the
purpose of examination & reporting
o Any case referred for expert
management & advice

Examples of Medical Legal Cases
1. All cases of injuries
2. All cases of burn
3. Alleged cases of assault
4. All cases of suspected or evident of
poisoning or intoxication
5. Case referred from court

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

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

• If any request is made for medical records either by patient,
authorized attendant or legal authorities, the documents shall
be issued within 72 hours & refusal to do so would be
misconduct.
• The following medical documents are almost important as for as
legalities are concerned:
1. Specialist consultations
2. Referral slips
3. Nurses record
4. Treatment record
5. TPR chart
6. BP monitoring chart
7. IO chart
8. Operative notes
MEDICAL DOCUMENTATION
9. Anesthetists notes
10. Progress report
11. Final diagnosis
12. Discharge summary
13. Follow up notes
14. Death certificate
15. Medico legal reports
16. Medico legal investigation
reports

USE OF RESTRAINTS
• Restraints are intervention that limits a person’s
freedom to move.
• It canbe:
a. physical
b. chemical.
• Researcher reported that the use of physical
restraint can lead to:
1. Skin trauma
2. Muscular atrophy
3. Nosocomial infection
4. Constipation
5. Incontinence
6. Limb injury
7. Contractures
8. Depression
9. Anger
10. Decline in functional
11. Decline in cognitive state
12. Increasing agitation

• Because restraints limit movement they
also limit autonomy.
NOTE:
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.
USE OF RESTRAINTS

DECISIONS REGARDING LIFE SUSTAINING
TREATMENT
• Usually there are TWO levels of treatment to consider:
a. Ordinary care (non invasive & treatments like
providing nutrition, hydration & antibiotic
therapy)
b. 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?

• 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 patient’s relative
orcaregiver.

• 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 bythe patient’srelative
• 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 consistentwith the
patient’s interests & preferences.

• 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.

• 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.
• Thefinal decision reflection the patient’s wishesshould 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 of 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 and 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 to learn the
process of identifying potential donors.
• The cost of intensive care treatment is very expensive &
time consuming. There is much debate today about whether
the outcomes from intensive care treatment off set the high
cost of prolonging life using technology & scientific know-how

ETHICAL ISSUES OF MOST CONCERN
The FIVE most frequently cited ethical issues reported by the
health care team surveyed were:
1. Protecting patients’ rights &human dignity
2. Providing care with possible risk to your health
(eg. TB, HIV, violence)
3. Respecting/not respecting informed consent to
treatment
4. Staffing patterns that limit patient access to nursing care
5. Use/non use of physical/chemical restraints

A combined analysis of reports revealed the following
as being the most personally disturbing issues faced by
the nurses surveyed:
1. Staffing patterns that limited patient access to
nursing care
2. Prolonging the dying process with inappropriate
measures
3. Working with an unethical/incompetent/impaired
colleague
4. Providing care with possible health risk
5. Not consideringapatient’s quality of life
ETHICAL ISSUES OF MOST CONCERN

WAYSTO 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 health care team working
in critical care areas has increased since 1990s.
• The health care team and 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.

QUESTIONS???

THANK YOU!
☺

Lecture 4 - Ethical & Legal Issues in Critical Cate Setup (1).pptx

Recommended

Recommended

More Related Content

Similar to Lecture 4 - Ethical & Legal Issues in Critical Cate Setup (1).pptx

Similar to Lecture 4 - Ethical & Legal Issues in Critical Cate Setup (1).pptx (20)

More from AnthonyMatu1

More from AnthonyMatu1 (20)

Recently uploaded

Recently uploaded (20)

Lecture 4 - Ethical & Legal Issues in Critical Cate Setup (1).pptx