Page 107 - ACCCN's Critical Care Nursing

84 S C O P E O F C R I T I C A L C A R E

in most of Europe, however in parts of Europe, life- stated objection from a family member, especially if the
sustaining treatments are withheld but not withdrawn as person has medical power of attorney (or equivalent), the
the withdrawal of therapies leading to death is consid- doctor must take this into consideration and respect the
ered illegal and unethical. In the Netherlands and rights of any patient’s legal representative. In that event,
Belgium, active life ending procedures are permitted and it is likely that withdrawal of treatment will not occur
performed with the specific intent of causing or hasten- until concordance is reached. (This is different in the case
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ing a patient’s death. In the US 35-37 and Europe the of a person who is legally declared brain dead; see Brain
majority of doctors have withheld or withdrawn life- death section.) 34
sustaining treatments.
In the Ethicus study of 4248 patients who died or had
The majority of the community and doctors favour active limitations of treatments in 37 ICUs in 17 European
life-ending procedures for terminally-ill patients. 39,40 In countries, life support was limited in 73% of patients.
the Ethicatt study, questionnaires on end of life decision- Both withholding and withdrawing of life support was
making were given to 1899 doctors, nurses, patients who practised by the majority of European intensivists while
were in ICUs and family members of the patients in six active life ending procedures despite occurring in a few
European countries. Less than 10% of doctors and nurses cases remained rare. The ethics of withdrawal of treat-
38
would like their life prolonged by all available means, ment are discussed in detail in the ANZICS Statement on
compared to 40% of patients and 32% of families. When Withholding and Withdrawing Treatment. The NHMRC
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asked where they would rather be if they had a terminal publication entitled Organ and Tissue Donation, After
illness with only a short time to live, more doctors and Death, for Transplantation: Guidelines for Ethical Practice for
nurses preferred being home or in a hospice and more Health Professionals provides further discussion of the
patients and families preferred being in an ICU. Differ- ethics of organ and tissue donation. 44
ences in responses were based on respondent’s country. 39,40
DECISION-MAKING PRINCIPLES
Diverse cultural, religious, philosophical, legal and pro-
fessional attitudes lead to great difference in attitudes and Despite significant advances in medical technology and
practices. Observational studies demonstrate that North therapeutics, approximately 20% of patients admitted
American health care workers consult families more often to ICUs do not survive and the majority of those die in
than do European workers, 39,41 and some seriously ill ICU after the forgoing of life-prolonging therapies (as
patients wish to participate in end of life decisions whilst opposed to after cardiopulmonary resuscitation). Lack of
others do not. 42 communication creates a potential for patients to under-
go burdensome and expensive treatments that they may
In most cases where there is doubt about the efficacy and not desire. Some doctors do not communicate with
appropriateness of a life-sustaining treatment, it may be patients or families or document decisions because of the
considered preferable to commence treatment, with an lack of clear laws for end-of-life practices and the fear of
option to review and cease treatment in particular cir- litigation. Many families want to be involved but some
cumstances after broad consultation. Inconsistency exists individual family members do not want to be involved
in decision making about when and how to withdraw in end-of-life decisions. Individuals commonly want
life-sustaining treatment, and the level of communication their family to decide for them, although the judgement
9
among staff and family. Documented guidelines for ces- of intensive care professionals concerning which treat-
sation of treatment are not necessarily common in clini- ment should be given may well differ from that of patients
cal practice, with disparate opinion a recognised concern and families.
in some cases. Dilemmas arise when there are disparate
views within the team as to what constitutes ‘futility’ and End-of-life decision making is usually very difficult and
with associated decisions regarding the next step or steps traumatic. Because of this difficulty, there is sometimes a
when a patient’s outlook is at its most grave. In a UK lack of consistency and objectivity in the initiation, con-
study that attempted to draft cessation of treatment tinuation and withdrawal of life-supporting treatment in
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guidelines, nursing staff were concerned over legality, a critical care setting. Traditionally, a paternalistic
morality, ethics and their own professional accountabil- approach to decision making has dominated, but this
ity. Medical decisions to withdraw treatment were shown stance continues to be challenged as greater recognition
to vary between medical staff and among patients with is given to the personal autonomy of individual patients. 9
similar pathologies. 43
Decision making in the critical care setting is conducted
Because ethical positions are fundamentally based on an within, and is shaped by, a particular sociological context.
individual’s own beliefs and ethical perspective, it may be In any given decision-making situation, the participants
difficult to gain a consensus view on a complex clinical hold different presumptions about their roles in the
situation, such as withdrawal of treatment. While it is process, different frames of reference based on different
essential that all members of the critical care team be able levels of knowledge, and different amounts of relevant
45
to contribute and be heard, the final decision (and ulti- experience. Nurses, for example, may conform to the
mately legal accountability in Australia and New Zealand dominant culture in order to create opportunities to par-
for the act of withdrawal of therapy) rests with the treat- ticipate in decision making, and thereby may conform to
ing medical officer. However, the decision-making process the values and norms of medicine. Although the nursing
certainly must involve broad, detailed and documented role in critical care is pivotal to implementing clinical
consultation with family and team members. If there is decisions, it is sometimes unacknowledged and devalued.