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Ethical Issues in Critical Care 87

absurd interventions as a result of not being able to claim discussion of autopsy, and immediate bereavement
categorically that a particular treatment will be useless. support. A goal of mastering the palliative skills necessary
The proposal is justified by appealing to the commonly to competently care for an actively dying patient is to
used statistical evaluation employed in clinical trials (P = enable a patient to die peacefully and as free of as much
0.01). A physiologically futile treatment may be, for discomfort as possible. Guiding and supporting family
example, cardiopulmonary resuscitation in the setting members during this time takes significant courage,
where the patient has a ruptured left ventricle. strength and fortitude from critical care nurses as they
maintain their duties of care in physical, psychological
There is no definition of futility in Australasian legisla-
tion, although there is limited guidance within some and spiritual ways.
Acts. An example is provided by the South Australian
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legislation referred to earlier : Euthanasia
Euthanasia, while being the subject of ongoing debate
[…] under no duty to use, or to continue to use, life sustaining across the globe over many years, remains illegal in Aus-
measures in treating the patient if the effect of doing so would tralia and New Zealand. Euthanasia is the termination of
be merely to prolong life in a moribund state without any real a very sick person’s life in order to relieve them of their
prospect of recovery or in a persistent vegetative state. (s17(2))
suffering. In most cases euthanasia is carried out because
the person who dies asks for it. Confusion has occurred
Do-not-resuscitate Considerations with some individuals unable to distinguish between the
in Critical Care process of withholding and withdrawing treatment and
Patients with acute, reversible illness conditions should that of euthanasia. The primary distinction relates to the
have the prerogative of resuscitation. Cardiopulmonary issue of ‘intent’. If the primary intention of the interven-
resuscitation (CPR) may be instigated in order to restore tion (e.g. a lethal injection) is to cause death, this may be
ventilation and circulation in patients, providing they do regarded as euthanasia and may be tested in court.
not have an irreversible or terminal illness. The decision However, if the primary intention of an act is to reduce
to withhold CPR may be termed a do-not-resuscitate pain and suffering, this may not be regarded as euthana-
(DNR) order in some jurisdictions. This reflects a deci- sia but may again be tested legally. The fact that the dif-
sion against any further proactive treatment such as CPR, ference between the two is complex and contentious adds
although there may be some limitations, such as ‘for to the vigorous debate by those ‘for’ and ‘opposed to’
defibrillation only’. Because each case must be considered euthanasia: an ongoing question for many years in many
on its merits, it is important to have clearly written countries. Religious opponents of euthanasia believe in
medical orders/directives so that misinterpretations do the sanctity of life and that life is given by God. Other
not occur. Paramount in these cases is clear discussion, opponents fear that if euthanasia was made legal, the
broad consultation and accurate documentation that laws regulating it would be abused, and people would be
reflects discussion between family and members of the killed who did not really want to die. Euthanasia is illegal
critical care team and any subsequent decisions. Any in most countries. Those in favour of euthanasia argue
directives must be clear to all those involved in the that a civilised society should allow people to die in
patient’s care. A management plan that incorporates dignity and without pain, and should allow others to
assessment, disclosure, discussion and consensus build- help them to do so if they cannot manage it on their own.
ing with the patient and family may be particularly The Netherlands legalised euthanasia, including doctor-
useful. 58 assisted suicide, in 2002. The law codified a twenty-year-
old convention of not prosecuting doctors who had
committed euthanasia in very specific cases, under very
Palliative Care in Critical Care specific circumstances. At times a patient may be influ-
59
Palliative care in the critical care unit occurs when a deci- enced to request the cessation of treatment as a conse-
sion has been made and documented to limit, withhold quence of unrelieved and enduring pain and suffering,
or withdraw treatment. Once it is evident that the patient’s and/or depression. In these circumstances, where such a
prognosis is grave and death likely to be imminent (albeit request may be thought to be inappropriate, it is proper
at times unpredictable in timing), it is the bedside critical to explore the patient’s feelings and treatment options
care nurse who becomes the leader in care provision for and perhaps to develop an agreed future treatment plan.
both the patient and their loved ones. It may be useful to obtain assistance from a counsellor
or other qualified professional. 58
Concepts in caring for the dying patient in a critical care
unit are no different from those in a hospital ward or
hospice. Privacy, dignity, a noise-free environment with Nursing Advocacy
minimal disturbance, relief of pain, provision of comfort, A commonly accepted view of nursing advocacy is where
support for both the patient and relatives, and coordina- the nurse is portrayed as helping the patient discuss his
tion of bedside visits are just a few key concepts, as is or her needs and preferences, helping the patient make
sensitive discussion (at the appropriate time) regarding congruent choices, supporting the patient’s decision, and
arrangements, wishes, belongings and cultural con- preventing others from impinging on the autonomy of
60
siderations after the patient’s death. Care does not end the patient. This view of nursing advocacy is reflected
with the death of the patient but continues through by the Australian Code of Ethics for Nurses: specifically,
death pronouncement, family notification of the death, nurses should ensure that patients are appropriately