Page 119 - ACCCN's Critical Care Nursing

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

an internationally accepted standard for the designing, incompetent regarding autonomous decision making.
conducting, recording and reporting of clinical trials. Hence, critical care nurses need to be familiar with guiding
ethical principles in the care of the critically ill, and with
The Australian government, through the NHMRC, has
funded and established the Australian Clinical Trial Regi- the ethical considerations relating to the conduct of clini-
stry (ACTR) at the NHMRC Trials Centre in Sydney, which cal human research. While a broad knowledge of these
complies with these requirements. Clinical trials can be principles is a requirement for all health professionals,
registered online. For trials commencing recruitment after because critical care nurses are often involved in these
1 July 2005, registration must occur prior to subject discussions and debates, they need to be particularly well
recruitment, as there are important implications for future informed, in order to actively participate in ethical deci-
research publication in journals. In parallel, as more sion making.
national trial registries emerge, the World Health Organi- Critical care nurses have a unique position, as they are at
zation is developing an approval process to assess trial the patient bedside around the clock and are often side-
register compliance. The WHO International Clinical Trial by-side with relatives for many hours at a time. Respon-
Registry Platform (ICTRP) is a global project to facilitate sibilities include acting as patient advocate, with often a
access to information about controlled trials and their counselling and listening role at the bedside with rela-
results. The Clinical Trials Search Portal provides access to tives of the critically ill. Medical officers in the critical care
a central database containing the trial registration data unit have additional legal responsibilities surrounding
sets provided by the registries listed on the right. It also consent and end-of-life decision making. A multidisci-
provides links to the full original records. To facilitate the plinary approach is therefore both useful and prudent to
unique identification of trials, the Search Portal bridges ensure all relevant ethical matters are considered appro-
(groups together) multiple records about the same trial. 96 priately and that treatments and care are conducted
according to guiding ethical principles. Issues of consent,
SUMMARY organ donation, guardianship, privacy, research and end-
of-life decision making are complex. The use of addi-
Effectively dealing with ethical issues in any healthcare tional supportive guiding processes and resources is
setting is complex and at times contentious. This is highly recommended to give the critical care nurse ade-
even more so in the critical care environment, where quate information on these ethical matters – those of
the patient cohort is predominantly vulnerable and paramount importance in the care of the critically ill.

Case study
Patients admitted to ICU frequently suffer from life-threatening Her temperature is 39.5 °C; WBC-15, 3000. Urine output is 30–40 cc/
situations. In a few instances, patients are non-responsive to ICU hr. She is sleepy but arousable.
therapies leading to the discontinuation of life sustaining interven-
tions (i.e drip of inotrope drugs, haemodialysis). A patient’s culture Her chest X-ray shows bilateral infiltrates and Mary is diagnosed
can influence many aspects of life, including family dynamics, with Pneumocystis carinii pneumonia. Mary was admitted to the
coping styles, and perceptions of death and dying, as well as the ICU for treatment. She is intubated, and treated with the appro-
expectations that people have from the health care system. Deci- priate drugs. Within 3 weeks, Mary was in septic shock, multi-
sions of patients, families and health care providers about health organ failure, unresponsive to high dose inotropic drugs, receiving
care at the end of life also depend on many factors. These include continual haemofiltration for acute kidney failure, spontaneous
relevant healthcare data, the doctor–patient relationship, institu- sub arachnoid haemorrhage and GCS of 3 without sedatives.
tional rules and regulations, and the general sociocultural, ethical, The ICU doctors and the haematology consultants consider that
legal and religious principles of the society. Several studies have any further treatments are futile and make the recommendation
shown that some of the differences in end-of-life decision making for therapy to be discontinued. The nursing staff has developed
are associated with local cultural factors. These differences fre- a close relationship with Mary’s husband, parents and the chil-
quently lead to conflicts in care decisions between health care staff dren, and do not feel ready to stop therapy. Mary’s parents and
and the patient’s family regarding continuation of life sustaining husband refuse to withdraw or withhold any therapies. They
interventions. believe that Mary should continue all treatments that she is
receiving now, and a natural course including palliative care
Mary is a 44-year-old wife and mother of 5 children; the youngest should be maintained. They are praying that a miracle will happen.
child is 5 years old. Mary and her family are very religious and The ethical challenges identified throughout this period were
devout Christian Scientists. She was diagnosed with acute lym- complex. There was mild dissent among nurses and medical staff
phatic leukaemia one month ago and has received two doses of at varying times, as personal belief systems reflected differing
chemotherapy. Last night Mary presented to the emergency views about Mary’s proposed treatment or cessation of treatment
department, primarily with the complaint of shortness of breath at and clinical course. There was a view in the last few days by a
rest. She is accompanied by her husband.
number of nurses that she had ‘suffered enough’ and her condition
Arterial blood gases results taken with many receiving 10L of O 2 was ‘futile’. The medical and nursing team felt that honouring the
via a face mask included: PaO 2 65 mmHg, PaCO 2 54; pH 7.50; patient’s and family’s religious belief was in conflict with the
BE+4.4; Lactate 4.9. healthcare situation. Nurses trained in cultural competence felt