This document discusses several key ethical and legal issues faced by critical care nurses, including informed consent, use of restraints, end-of-life decisions around life-sustaining treatment, organ donation, and resolving ethical problems. It outlines important ethical principles like autonomy, beneficence, and justice. It also addresses issues like medico-legal cases, documentation, and the most concerning ethical issues reported by nurses.

1. Dr. Jayesh Patidar
PhD., M.Sc. Nursing, MBA
Asst. Professor
Joitiba College of Nursing, Bhandu.

2. • 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.

3. Ethical Principles
• Autonomy
• Beneficence
• Nonmaleficence
• Justice
• Veracity
• Fidelity

4. 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.

5. Legal and Ethical Issues Informed
Legal and Ethical Issues Informed
Consent
Consent
• It implies to permission by the patient to perform
an act on his body either for diagnosis or
therapeutic procedure.
• The four elements of consent are;
voluntariness
capacity
knowledge
Decision making

6. Type of consent
1. Implied Consent
2. Expressed consent: (verbal written)

7. Points to be considered in consent
• Consent must be given voluntarily
• If patient is not mentally capable (critical patients)
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.

8. • 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.

9. MEDICO LEGAL CASE
• 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.

10. MEDICO LEGAL CASE
• Request of the patient or relatives or
friend for not registering the case as
medico legal should not be accepted.
• The MLC should be registered as soon
as physician suspect’s foul play or case
brought several days after the
incident.
• The MLC is received in hospital by; any
case brought by police for the purpose
of examination & reporting & any case
referred for expert management &
advice.

11. Following Cases Should be Considered As
MLC& to be Intimate To The Police
Regarding Such Cases,
• All cases of injuries
• All cases of burn
• Alleged cases of assault
• All cases of suspected or
evident of poisoning or
intoxication
• Case referred from court

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

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

14. MEDICAL DOCUMENTATION
• If any request is made for medical records either by
patient/authorized attendant/legal authorities, the
documents shall be issued within period of 72 hours
& refusal to do so would be misconduct.
• The following medical documents are almost
important as for as legalities are concerned: specialist
consultations & referral slips, nurses
record, treatment record, TPR chart, BP monitoring
chart, IO chart, operative notes, anesthetists
notes, progress report, final diagnosis, discharge
summary & follow up notes etc. as for as medical legal
issues are concerned e.g. death certificate, medico
legal reports, medico legal investigation reports, all
are of immense important & have to be very specific.

15. USE OF RESTRAINTS
• Restraints are intervention that limits a
person’s freedom to move. It can be
physical or chemical.
• Researcher reported that the use of
physical restraint can lead to: skin
trauma, muscular atrophy, nosocomial
infection, constipation, incontinence,
limb injury, contractures, depression,
anger, decline in functional & cognitive
state & increasing agitation.

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

17. DECISIONS REGARDING LIFE SUSTAINING
TREATMENT
• Usually there are two levels of treatment to
consider is: ordinary care (non invasive &
treatments like providing nutrition, hydration
& antibiotic therapy) & 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.

18. 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?

19. Count…
• 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 or caregiver.

20. Count…
• 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 by the patient’s relative
• Withholding or stopping resuscitation efforts is
ethically & legally appropriate if the
patient/surrogate has previously made his
preferences known through advanced directives.

21. 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
consistent with the patient’s
interests & preferences.

22. Count…
• 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.

23. Count…
• 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.
The final decision reflection the patient’s wishes should
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.

24. Points to be considered
• Withdrawal of life support is indicated
if the patient has Glasgow coma score
is 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, honest
information.
• Keep the discussion on
withholding/withdrawing life support
based on patient wishes & the burden
versus benefits of the various options

25. 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.

26. • 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.

27. • 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 critical care nurses to
learn the process of identifying potential donors.
• Cost versus outcome – an ethical issue?
• The cost of intensive care treatment is very expensive &
time consuming. There is much debate today in both the
nursing literature & popular press about whether the
outcomes from intensive care treatment off set the high
cost of prolonging life using technology & scientific know-
how

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

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

30. WAYS TO 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.

31. • The ethical & legal responsibility of nurse working in
critical care areas has increased since 1990s. 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.