v3

Ethical and legal

issues in critical c
are nursing and
end-of-life
nursing care

Chapters 3 & 4
 Objectives
1. Describe ethical obligations and nurse advocacy in critical care nursing.
2. Apply the components of a systematic, ethical
decision-making model.
3. Discuss ethical principles related to critical care
nursing.
4. Describe the importance of increasing nurses’
involvement in ethical decision-making.
5. Discuss ethical issues that arise in the critical care
setting.
6. Describe ethical and legal concerns related to end-of-life care.
7. Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or withdrawing therapy;
and psychological support of the patient, family members, and
health care providers.
8. Discuss cultural considerations in end-of-life care.
 Nurse Advocacy

Obligation to protect patients’ welfare Serve as patient

advocates.

Nurses’ ethical obligation to serve as advocates for their

patients is derived from the unique nature of the nurse-
patient relationship.

Professional organizations promote ethics and advocacy

 American Nurses Association
 Code of Ethics for Nurses with Interpretive
Statements
 American Association of Critical-Care Nurses
 An Ethic of Care

[Link]
Ethical Decision-Making

An ethical dilemma is a difficult problem or situation in which conflicts arise during the process of making
morally justifiable decisions.

Ethical Dilemma Warning Signs

Emotionally charged

Significant change in patient’s condition

Confusion about facts

Hesitancy about the correct set of actions

Deviation from customary practice

Need for secrecy regarding proposed actions

Ethical Decision-Making
Process
Ethical Principles

Autonomy Justice
• Right of self-determination • Fair distribution of health care resources
concerning medical care
Veracity
Beneficence • Truthfulness

• Duty to do good, prevent harm,

remove harm, and promote the Fidelity
good of another person • Faithfulness to commitment

Nonmaleficence Confidentiality

• Not to intentionally inflict harm • Respect for right to control information

 Nurse Involvement in Ethical Decision Making
Limited involvement in the formal processes
of ethical decision making
Ethics education has a significant positive influence on moral confidence, moral action, and use of ethics resources by n
urses.

Dilemmas can result in moral distress

Open communication of patient’s wishes and ethical concerns
True collaboration with healthcare team members

Formal mechanisms (The Joint Commission)

Bioethics committees
Ethics consultation

Opportunities for critical care nurses

Institutional Ethics Committee membership
Ethics forums and rounds
Peer review
Quality Improvement Committee membership
Institutional review boards (research)
Nurse Involvement in Ethical Decision Making
 Selected Ethical Topics In Critical Care
Informed Consent
informed consent is based on the principle of autonomy; competent adults have the right to
self-determination or to make decisions regarding their acceptance or rejection of treatment.

Elements of Informed Consent

1. Competence: ability to understand information- mental capacity (illness or treatment)

2. Voluntariness: consent without coercion
3. Disclosure of information
Diagnosis
Proposed treatment
Probable outcome
Benefits and risks
Alternative treatments
Prognoses if treatment is not provided

Informed consent is not a form. It is a process.

 Selected Ethical Topics In Critical Care

Decisions Regarding Life-Sustaining Treatment

Factors to consider: Ordinary care
Constitutional rights
Quality of life • Common, noninvasive, and tested
Impact of advanced technology treatment
Medical Futility • Nutrition, hydration, antibiotics
Ordinary versus extraordinary care
Extraordinary care

• Complex, invasive, experimental

treatment
• ACLS, dialysis, unproved therapies
Advance Directive

Communication about preferences for treatments if patient is incapacitated

Do not resuscitate (DNR)

Natural death
Living will
Treatments desired and what should be withheld
Durable power of attorney for healthcare
Determines who makes decisions
Health care surrogate or proxy
Quick Quiz!

The nurse recognizes which statement as a potential ethical issue?

A. “The physician explained my mother’s poor prognosis.”

B. “If the breathing machine is helping my mother, why is the doctor asking me about
removing the breathing tube?”
C. “My mother has designated my brother to make decisions.”
D. “Can I assist with some of my mother’s care?”
 Chapter 4
Palliative and End-of-Life Care
in the Critical Care Unit

Copyright © 2017 Elsevier Inc. All rights reserved.

 Critical Care Nursing
End of Life
 Alleviation of distressing symptoms (palliation)

 Communication and conflict resolution

 Withdrawing, limiting, or withholding of therapy

 Emotional and psychological care of the patient and family

 Caregiver organizational support

Copyright © 2017 Elsevier Inc. All rights reserved. 14

 Palliative Care

 Designed to relieve
symptoms and pain
management
 Should be implemented
with ALL patients, not
just the dying
 Improve the
communication between
healthcare providers and
patient and family
 Decrease anxiety and
distress

Copyright © 2017 Elsevier Inc. All rights reserved. 15

 Palliation

Elements of Palliative Care Nursing Interventions for

 Early identification of end-of-life patients Palliative Care

 Pain management as “fifth vital sign” Frequent repositioning

 Pharmacological and nonpharmacological Good hygiene

interventions to: Skin care
 Relieve pain Creation of a peaceful
 Control anxiety environment
 Control other distressing symptoms Pain relief

Copyright © 2017 Elsevier Inc. All rights reserved. 16

 Communication and Conflict Resolution

 Provide clear, ongoing, honest communication

 Allow time for family members to express themselves

 Agree on a treatment plan

 Emphasize that patient will not be abandoned

 Facilitate continuity of care

Copyright © 2017 Elsevier Inc. All rights reserved. 17

 Withholding, Limiting, or Withdrawing Therapy

 Usually precedes most critical care deaths Withdrawal of treatment

 Does not constitute euthanasia or assisted suicide Discontinuation of life-sustaining therapies
in a terminally ill or persistently vegetative
 Shared decision-making model patient

Withholding of treatment
Failure to initiate life-sustaining therapies in
a terminally ill or persistently vegetative
patient

Copyright © 2017 Elsevier Inc. All rights reserved. 18

 Ethical Principles Related to Withdrawal and
Withholding of Treatment

 Death is a product of the underlying disease

 Goal is to relieve suffering, not hasten death

 Withholding life-sustaining treatment is moral equivalent of withdrawing treatment

 Any treatment may be withheld or withdrawn with patient and family consent
 Any dose of analgesic or anxiolytic medication may reasonably be used to control pain
and relieve suffering
 Life-sustaining treatment should not be withdrawn from patients on paralytic agents

 Cultural and religious perspectives may affect patient and family decision making

19
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 Commonly Withheld Therapies

 Ventilator Withdrawal

 Vasopressors
 Antibiotics

 Blood and blood products

 Nutritional support

 Possible deactivation of implanted devices (ICDs)

Copyright © 2017 Elsevier Inc. All rights reserved. 20

Nursing Interventions During Withdrawal or
Withholding of Treatment

 Assess and ensure patient comfort

 Provide anticipatory guidance to patient and family

 Anticipate distressing symptoms and medicate to relieve

symptoms
 Titrate therapy to relieve emotional and physical distress

21
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 Hospice Care

Nursing Interventions
 Emphasizes comfort rather than cure • Ongoing assessment of response to
therapy and comfort
 Views dying as a normal process • Pharmacological and
nonpharmacological symptom
 Philosophy of care, not a location
management
 Common in oncology • IV benzodiazepines for anxiety
• IV morphine for dyspnea and
 Appropriate when aggressive pain
interventions are withdrawn • Guidelines for pharmacological
interventions for end-of-life
 Quality end-of-life care

Copyright © 2017 Elsevier Inc. All rights reserved. 22

 Emotional and Psychological Care

 Variable interventions based on the patient’s and family’s needs

 Nonjudgmental, culturally sensitive assessments

 Family involvement (comfort them) and unrestricted family visit

 Spiritual counseling if appropriate

 Clear, concise information

 Bereavement counselor

 Life story (listen)

**Box 4.5, p. 47
Copyright © 2017 Elsevier Inc. All rights reserved. 24
Caregiver Organizational Support

 Adequate staffing

 Conduct family meetings and develop plan of care

 Assistance with funeral arrangements

 Educate the public

 Professional development classes

25
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 Cultural Competence in End of Life

 Most clinicians feel ill-prepared

Whispering of the
Testament of faith
 Cultures differ in death practices
 Cultures differ in end-of-life options
selection
 Become familiar with common cultures in
the service area
 Become familiar with religious groups and
beliefs about end of life

Copyright © 2017 Elsevier Inc. All rights reserved. 26

Select the pharmacological classification that is not usually withdrawn at the end of life.

A. Vasopressors
B. Opiates
C. Antibiotics
D. Loop diuretics

27
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THANK YOU