Ethics in ICU

Barbara Stanley FRCA

ICU Curriculum - Ethics

• Basic ethical principles: autonomy, beneficence, non-maleficence, justice

• Ethical and legal issues in decision-making for the incompetent patient: incapacity

• Confidentiality and data protection - legal and ethical issues• Understand the legislative framework within which healthcare is

provided in the UK and/or devolved administrations, in particular – death certification and the role of the Coroner/Procurator Fiscal; child protection legislation; mental health legislation (including powers to detain a patient and giving emergency treatment against a patient’s will under common law); advanced directives and living Wills; withdrawing and withholding treatment; decisions regarding resuscitation of patients; surrogate decision making; organ donation and retention; communicable disease notification; medical risk and driving; Data Protection Act and Freedom of Information Act; provision of continuing care and community nursing care by a local authorities

Case 1

• Mr Jones 68 yrs old – Emergency repair AAA Has chronic COPD

• Failed extubation• Now needs Tracheostomy• How will you gain his consent?• His cousin keeps telephoning from abroad and

asking for an update on his condition – the nurse has asked you to speak to him

Case 2

• Called to resus for a patient who is thought to have taken an overdose having been found at the bottom of the stairs.

• He is refusing to allow anyone to assess him. He is violent and aggressive and security are currently preventing him from getting up from the trolley

• You are asked to sedate him so he can be scanned and have bloods taken. He is swearing and threatening to sue you if you touch him

• How will you proceed?

Case 3

• Mr C – 36 yr old motorcyclist• C4 # = Quadriplegic but can communicate

clearly• Requests withdrawl of care• Wife and sister upset and don’t want this –

say he is depressed – requesting more time

Case 4

• Mr J is 32yrs old• Admitted with pneumonia and is septic• He is sedated and ventilated• You are putting in a CVP and accidentally get a

needlestick from the 16g needle• What should you do next?• Should the patient have HIV/ Hepatitis test?

• Turns out to be PCP• Dx HIV• Does not want his pregnant wife to be told• She is asking for the diagnosis

Case 5

• Claire is 15yrs old and was involved in an RTA. She has leg fractures but can communicate effectively

• Her Hb is 6.1g/dl due to her injuries• Her parents are Jehovas Witnesses and have

refused to allow her to have blood• Overnight she has haematemesis, becomes

distressed and consents verbally to a transfusion – which she is given

• Her parents are furious and want to speak to the doctor

Case 6

• Mr Gupta is 49 and comes to ICU with TBI• After 72 hours - brain stem tests show he is

dead• He has a donor card in his wallet• His family are adamant they do not think he

wanted to be an organ donor because of his religious beliefs

Case 7

• Mrs D is 49 - Emergency laparotomy during the night for perforated duodenal ulcer

• Recently diagnosed with metastatic ovarian Ca – the oncologists say she would have only months left to live

• ICU post op - not done well requiring inotropes and ventilation

• Now has AKI with a rising creatinine, high lactate and metabolic acidosis – needs the filter

• Her daughter tells you that she has a living will and she would not want futile treatments

Summary – 4 main principles

• Autonomy is the desire for self – governance or self rule• Maximal autonomy is the level of autonomous choice

possible considering the given circumstances.

• Beneficence – Moral obligation to act for the benefit of others

• Non Maleficence – Refraining from actions that do harm

• Justice – decisions based on clinical need – not race/sex/religion

Summary points

• Competence is a legal state– Refers to the degree of mental soundness necessary to

make decisions about a specific issue or to carry out a specific act

– Only a court can make a determination of incompetence.– It is decision specific

• Capacity – an individual's ability to make an informed decision. Any

licensed physician may make a determination of capacity

Mental Capacity Act 2005

• A patient may lack mental capacity if they are unable:– to understand the information relevant to the

decision– to retain that information– to use or weigh that information as part of the

process of making the decision, or– to communicate his decision (whether by talking,

using sign language or any other means).

“Best Interests”• On each occasion that treatment is required for a patient with

limited capacity to consent, a decision is made in the best interests of the patient.

• In assessing best interests, the Mental Capacity Act states the following should be considered– The past and present wishes of the patient (especially any

written statement when the patient had capacity)– Religious beliefs or values expressed by the patient when

competent– The views of relevant others (carers, relatives, etc) – The patient should be involved in the consent process and,

where appropriate, encouraged to give their consent to particular aspects for which they do have capacity

Restraint

• Section 6 of the MCA 2005 authorizes the use of force or restraint if the measure is reasonably expected to prevent harm to the patient– Must be proportional to the liklehood and

seriousness of harm– Only for those without capacity

Withdrawing Treatment and Futility

• If the patient has capacity – respect their wishes

• law regards discontinuing life support as ‘no different from not initiating it in the first place’

• If no capacity – apply “best interests” principle

Gillick Competence and Fraser Ruling

• The legal age for consent is 16 yrs old (Section 8 Family Law Reform Act 1965)

• Under 16’s reviewed in 1985 (Fraser Ruling) = Consent may be given if the health professional is satisfied that:– Child understands risks/benefits of treatment or advice– Discussion with parents advised – reasons for not doing so

explored– The childs physical/mental health will suffer if

treatment/advice witheld– Deemed Fraser Ruling competent

Advanced Directives

• Prolong autonomy• Recognised in court as legally binding• Cannot ask for inappropriate treatment or lethal injection to

end life• “Where there are good grounds for genuine doubt about the

validity of an advance refusal, there should be a presumption in favour of life and emergency treatment should be provided. Treatment may, however, be withdrawn at a later stage should the validity, or existence, of a valid advance directive become clear" (Section 10.2)

DNAR

• British Medical Association/Royal College of Nursing. Decisions Relating to Cardio-Pulmonary Resuscitation(2002) Paragraph 10– The patient’s condition is such that effective cardio-

pulmonary resuscitation will not be successful.– When there is no benefit in restarting the patient’s heart

(if, for example, imminent death cannot be avoided).– Where the expected benefit is outweighed by the burdens

(e.g. where there is a high risk of substantial brain damage)

Questions ?

Take Home Points

• Competence and Capacity assumed > 16yrs• Get their consent• Lack of capacity is decision specific• What would they want (family/friends or

Power of Attorney/ Mental Capacity advisor)• Best Interests• If in doubt – Continue treatment/ resusitate