ST. MARY’S COLLEGE OF TAGUM, INC.
NURSING PROGRAM
LEARNING
NCM 118 - CARE OF CLIENTS WITH LIFE-THREATENING CONDITIONS,
ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY
MODULE
SITUATION
BSN4
Lesson 3: Ethico-Legal Considerations
in the Critical Care
Prepared by:
JOSEFINA S. BALOTE,RN,MN
Module 1 – Lesson 1
Timothy 5:8 “Then your
light will break forth like
the dawn, and your
healing will quickly
appear; then your
righteousness will go
before you and the glory
of the Lord will be your
rear guard.”
2
Module 1 – Lesson 1
Ignacian Core/ Related
Values:,
Excellence; service, Faith
3
Module 1 – Lesson 1
Learning Outcomes
At the end of the lesson the students can:
1. Discuss the ethico-Legal Responsibilities in the
Critical Care Unit Nursing
2. With a given scenario formulate a plan of action to
address the nursing needs and problems of the client.
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Introduction
This unit introduces the ethico-legal considerations in
critical care nursing
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Learning Contents
Ethico-Legal Considerations in the Critical
Care
Patient Safety Guidelines in Critical Care
Ethical and Legal considerations in the Care of
the Critically Ill
Scope of Nursing Practice based on R.A. 9173
Patient’s Bill of Rights and Obligations:
Unconscious Client
6
Learning Contents
Ethico-Legal Considerations in the Critical
Care
Patient Safety Guidelines in Critical Care
Ethical and Legal considerations in the Care of
the Critically Ill
Scope of Nursing Practice based on R.A. 9173
Patient’s Bill of Rights and Obligations:
Unconscious Client
7
Learning Contents
Ethico-Legal
Considerations in the
Critical Care
ETHICAL PRINCIPLES
Autonomy – Patient’s right to self determination
Non-maleficent – do no harm
Beneficence – Promoting good
Veracity – the obligation to tell the truth
Fidelity – faithfulness to agreements and
responsibilities
Justice – the fair allocation of medical resources
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
ETHICAL DILEMMAS EXPERIENCED BY
NURSES WORKING IN CRITICAL CARE UNITS
Identified “end-of-life decisions,
Patient care issues and
Human rights issues
How to resolve the dilemma?
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
PRACTICAL PRINCIPLES FOR ETHICAL
DECISION MAKING
Identify source of authority for decision making
Achieve effective communication with patient
and families
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
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
RECOMMENDATIONS FOR END-OF-LIFE
CARE IN ICU : A CONSENSUS STATEMENT BY
THE AMERICAN COLLEGE OF CRITICAL CARE
MEDICINE
Concluded that End-of-life care is emerging
comprehensive area of expertise in the ICU and
highlighted the importance of shared decision
making and the importance of caring for patients’
families
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
PALLATIVE 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
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
CPR DESISIONS
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.
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
EUTHANASIA
Is a Greek word meaning “good death”, is
popularly known as “mercy killing”
Active
Passive
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
WITHHOLDING OR WITHDRAWAL OF LIFE
SUPPORT
WITHHOLDING: never initiating a treatment
WITHDRAWING: to stop a tratment nce started.
Best made after careful discussion (health care
professional, patient and family)
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
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
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
PERCEPTIONS OF “FUTILE CARE” AMONG
CAREGIVERS IN ICU
Respondents felt that futile care was provided
because of family demands, a lack of
consensus among treating team
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
LEGAL DECISIONS IN CRITICAL CARE UNITS
Medical Documentation
Use of Restraints
Declaring Brain Death
Passive Euthanasia
Organ Donation
Autopsy
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
MEDICAL DOCUMENTATION
Informed Consent
Advanced Directives
Incident Reports
IF YOU DIDN’T DOCUMENT IT, YOU
DIDN’T DO IT
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
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.
IF YOU DIDN’T DOCUMENT IT, YOU
DIDN’T DO IT
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
INCIDENT REPORTS
document the occurrence bof 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 potentially or
actually harmful incident or who witnesses an
injury is the one who fills out the incident
form.
IF YOU DIDN’T DOCUMENT IT, YOU
DIDN’T DO IT
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
OTHER IMPORTANT LEGAL DOCUMENTS
consultations and referral slips
Nurses record
Treatment and investigation record
TPR Chart, BP monitoring chart, I&O,
Progress Report
Operative Notes, Anesthesia notes
Final Diagnosis
Discharge Summary and follow up notes
Death Certificate
WRITE IT ALL DOWN!
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
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
WRITE IT ALL DOWN!
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
NURSES’ RELATED FACTORS INFLUENCING
THE USE OF PHYSICAL RESTRAINT IN ICU
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
WRITE IT ALL DOWN!
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
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:
A. coma
B. absence of brainstem reflexes
C. apnoea
WRITE IT ALL DOWN!
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
PASSIVE EUTHANASIA
it is legal in India. On 7th March 2011 the
Supreme Court Of India legalized passive
euthanasia by means of withdrawal of life
support to patients in permanent vegetative
state
WRITE IT ALL DOWN!
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
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 ( Philippines: epublic Act
No. 7170 of 1991, Amended by Republic Act No. 7885
1st brain death donor kidney transplant
was performed on May 2017
POS-982 A CASE REPORT OF THE FIRST
DECEASED ORGAN DONOR IN THE PHILIPPINES
DURING THE COVID-19 PANDEMIC
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
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
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
PATIENT’S BILL OF RIGHTS
1. Right to considerate
Right to information
Right to make decisions
Right to mhave advance directives
Right to privacy
Right to confidentiality
Right to mreview the records
Right to proper treatment and referral
Right to ask and be informed of the existing
business relationship among hospital,
educational institutions, other health care
providers or payers
Right to consent to participate in research
Right to reasonable continuity of care
Right to be informed of hospital policies
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
MEDICO LEGAL CASES
All cases of injuries
All cases of burn
Alleged cases of assault
All cases of suspected or evident of
poisoning or intoxication
Vases referred from court
Cases of suspected or evident of abortion
Cases of unconscious/comatose where its
cause is not natural or not clear
Cases brought dead/ dead on arrival/ sudden
unexpected death
Cases of suspected self inflicted injuries or
attempted suicide
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Learning Contents
Ethico-Legal
Considerations in the
4 “A”s
Critical and 4 “R”s (American Asso of Critical-
Care
care Nurses (AACN)
4”A”s – sequential steps in raising one’s
awareness and committing to action
1. ASK – reflect to become aware of your
feelings of moral distress. “ Am I 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
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
4 “R”s (American Asso of Critical-care
Nurses (AACN) – helps clarify your
uncertainties
[Link] – in what ways and to who is
the issue important?
[Link] – what are the risks of taking action
and of NOT taking action?
[Link] – what benefits can be obtained
by acting various courses of action/
[Link] – what are the barriers to
taking action or a particular course of action?
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
LEGAL SAFEGUARDS FOR NURSES
1. 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
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SYNTHESIS
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Learning Contents
Ethico-Legal
Considerations in the
Critical Care
ETHICAL DILEMMAS EXPERIENCED BY
NURSES WORKING IN CRITICAL CARE UNITS
IDENTIFIED “END-OF-LIFE DECISIONS,
palliative care
CPR decisions
Euthanasia
Withholding and withdrawing treatment
Futile care
How to resolve the dilemma?
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Learning Contents
Patient Autonomy,
Three elements to the psychological capacity of
autonomy:
A. agency,
B. independence, and
C. rationality.
Agency is awareness of oneself as having desires
and intentions and of acting on them.
Independence refers to the actual state of being
free from other people's influence or control
Rationality refers to the act of determination
of the self by itsef
In acute care, the patient has decisional and
executive autonomy
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Learning Contents
Patient Autonomy,
Adherence to complex treatments commonly
breaks down when patients have functional,
educational, and cognitive barriers that impair
their capacity to plan, sequence, and carry out
tasks associated with chronic care.
in acute-care paradigm the patient has the role
in medical decisions. The adult patient is
presumed to have adequate capacity to
understand and make decisions, i.e., to
possess decisional autonomy, and therefore is
presumed to have the capacity to participate in
decisions about his or her medical care
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Learning Contents
Patient Autonomy
The ethical principle of respect for autonomy
requires that the patient with decisional autonomy
be accorded authority over what will or will not be
done regarding his or her medical care (
Beauchamp and Childress 2001)
From the perspective of decisional autonomy,
behaviors or outcomes that are incongruent with
the treatment plan are interpreted by clinicians as
either an autonomous refusal of the physician’s
recommendations or the result of significant
impairments in decisional autonomy that need to
be assessed and responsibly managed.
Some patients with chronic conditions may
articulate understanding of the management plan
and appear non-adherent when actually they are
unable to implement the steps necessary to meet
the treatment objectives.
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ASSESSMENT
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