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Ethical Issues in Critical Care 83

● A disclosure of appropriate alternative procedures or promises of added benefits, and fewer side effects, and
courses of treatment, if any, that might be advanta- are heralded by drug companies and journals across the
geous to the subject world. Combinations of these therapies in critical care
● A statement describing the extent, if any, to which units are part of everyday management of critically ill
confidentiality of records identifying the subject will patients. While technology is capable of maintaining
be maintained some of the vital functions of the body, it may be less
● For research involving more than minimal risk, an able to provide a cure. Managing the critically ill patient
explanation as to whether any compensation, and an in many cases represents a provision of supportive, rather
explanation as to whether any medical treatments are than curative, therapies. 29
available, if injury occurs and, if so, what they consist A common ethical dilemma found in critical care is related
of, or where further information may be obtained. to the opposing positions of ‘maintaining life at all costs’
● An explanation of whom to contact for answers to and ‘relieving suffering associated with prolonging life
pertinent questions about the research and research ineffectively’. Patients that would probably have previ-
subjects’ rights, and whom to contact in the event of ously died can now be maintained for prolonged periods
a research-related injury to the subject on life support systems, even if there is little or no chance
● A statement that participation is voluntary, refusal to of regaining a reasonable quality of life. Assessment of
participate will involve no penalty or loss of benefits their ‘post-critical illness’ quality of life is complex,
to which the subject is otherwise entitled, and the emotive and forms the basis of significant debate, com-
subject may discontinue participation at any time pounded by the nuances of each individual patient’s case.
without penalty or loss of benefits, to which the Hence, decisions regarding withdrawal and withholding
subject is otherwise entitled.
of life support treatment(s) are not made without sub-
Consent to conduct research involving unconscious indi- stantial consideration by the critical care team. 30
viduals (incompetent adults) in critical care is one of the
situations not comprehensively covered in most legisla-
tion (see also Ethics in research later in this chapter). WITHDRAWING/WITHHOLDING TREATMENT
The incidence of withholding and withdrawal of life
Consent to collection, use, disclosure of support from critically ill patients has increased to the
health information extent that these practices now precede over half the
31
It is important to distinguish between health information deaths in many ICUs, although the incidence in other
critical care areas has not been reported. Although there
use (internal to an organisation) and disclosure (external is a legal and moral presumption in favour of preserving
dissemination) (see also responsible practices in Ethics life, avoiding death should not always be the pre-eminent
19
in research section later in this chapter).
32
goal. The withholding or withdrawal of life support is
Application of Ethical Principles in considered ethically acceptable and clinically desirable if
the Care of the Critically Ill it reduces unnecessary patient suffering in patients whose
prognosis is considered hopeless (often referred to as
Critical care nurses should maintain awareness of the ‘futile’) and if it complies with the patient’s previously
ethical principles that apply to their clinical practice. The stated preferences. Life support includes the provision of
integration of ethical principles in everyday work practice any or all of ventilatory support, inotropic support for the
requires concordance with care delivery and ethical prin- cardiovascular system and haemodialysis, to critically
ciples. There is a risk that nurses may become socialised ill patients. Withholding/withdrawal of life support are
into a prevailing culture and associated thought pro- processes by which healthcare therapy or interventions
cesses, such as the particular work group on their shift, either are not given or are forgone, with the understand-
the unit where they are based, or the institution in which ing that the patient will most probably die from the
they are employed. Depending on the prevalent culture underlying disease. 33
at any one of these levels, nursing practice may be highly
ethical or less ethically justifiable. The ‘group think’ In Australia, when active treatment is withdrawn or with-
approach of ‘That’s how we’ve always done it’ requires held, legally the same principles apply. The Australian
critical reflection on what is the ethical or ‘right thing to and New Zealand Intensive Care Society (ANZICS)
28
do’. Clinical audits and other dedicated review systems recommends an ‘alternative care plan’ (comfort care) be
and processes are useful platforms for ethical discussion implemented with a focus on dignity and comfort. All
and debate between critical care colleagues. discussions should be recorded in the medical records
including the basis for the decision, who has been
END-OF-LIFE DECISION MAKING involved and the specifics of treatment(s) being withheld
34
or withdrawn. There are marked differences in the ‘fore-
With advances in technology in health care, it is possible going of life-sustaining treatments’ that occur between
more than ever before to restore, sustain and prolong life countries and in the patient level of care variation even
with the use of complex technology and associated thera- within the same country. What may be adopted legally
pies, such as mechanical ventilation, extracorporeal oxy- and ethically or morally in one country may not be
genation, intra-aortic balloon counterpulsation devices, acceptable in another. The withholding and withdrawing
haemodialysis and organ transplantation. In addition, of therapies is considered passive euthanasia and is
new medication treatment options contribute significant legal and accepted practice in terminally-ill ICU patients