WEEK 7 (INTRODUCTION TO CRITICAL CARE)

CRITICAL CARE NURSING

The health care industry all over the world has been undergoing great changes over the
past two decades and the Philippines has been part of these transformational events having great
impact on the quality of nursing practice. There are new expectations in the way nurses and the
nursing practices are to be delivered particularly now that there are many challenges that besiege
the present time as a consequence of the complexities of globalization.
In the Philippines, the Professional Regulation Commission – Board of Nursing (PRC-
BON) is committed to provide need-driven, effective and efficient specialty nursing care services
of high standard and at international level within the obtainable resources. To respond to this
mission and commitment, a PRC-BON Working Group in Developing the Nursing Specialty
Framework was formed sometime in 1996 to take on the task of setting the process-based
framework and guidelines for specialty nursing services. Working Group members comprise
clinical nurse practitioners, nurse educators and nurse managers.
However, the expanding healthcare and nursing knowledge together with new and
evolving healthcare sites, structures, and technologies all have contributed to the need and desire
for specialty nursing organizations like the Critical Care Nurses Association of the Philippines,
Inc. (CCNAPI) to revisit the existing statement of its Standards of Nursing Practice in order to
provide clear and updated statements regarding the scopes of practice and standards of critical
care nursing. This will ensure continued understanding and acknowledgment of nursing’s varied
specialty professional contributions in today’s healthcare environment.
 Critical care nursing is that specialty within nursing that deals specifically with human
responses to life-threatening problems. These problems deal dynamically with human
responses to actual or potential life-threatening illnesses.
 The framework of critical care nursing is a complex, challenging area of nursing practice
which utilizes the nursing process applying assessment, diagnosis, outcome
identification, planning, implementation, and evaluation.
 The critical care nursing practice is based on a scientific body of knowledge and
incorporates the professional competencies specific to critical care nursing practice and is
focused on restorative, curative, rehabilitative, maintainable, or palliative care, based on
identified patient need.
 It upholds multi and interdisciplinary; collaboration in initiating interventions to restore
stability, prevent complications, achieve and maintain optimal patient responses.
 The critical care nursing profession requires a clear description of the attributes,
guidelines and nursing practice standards in guiding the critical care nursing practice to
fulfill this purpose.
The critical care nursing competencies statements developed in 2005 are aligned with the
PRC-BON statement of the 11 Core Competencies for Entry Level for Safe and Quality Nursing
Care. The CCNAPI Core Competencies of a Critical Care Nurse are stated according to the
levels of expected behaviour defining the actual knowledge, skills and abilities in the practice of
critical care by a nursing professional. These statements cover expected behavior of a Nurse
Clinician I, Nurse Clinician II and Nurse Specialist that will serve as the basis for assessing
competence in critical care practice.
PHILOSOPHY OF CRITICAL CARE NURSING
Critical care nursing reflects a holistic approach in caring of patients. It places great
emphasis on caring the bio-psycho-social-spiritual nature of human beings and their responses to
illnesses rather than the disease process. It helps to maintain the individual patient’s identity and
dignity. The caring focus includes preventive care, risk factor modification and education to
decrease future patient admission to acute care facilities.
The Critical Care Nurses of the Philippines, Inc. (CCNAPI) believes that as an
organization of critical care nurses, it is conscious of its responsibility for the promotion of
man’s health and welfare for national development, and has the desire to give support for
professional and personal growth and development.

CCNAPI has organized itself into a national association

committed to the ideals of service to the people, equality, justice and social progress.
In the Critical Care Units, each patient is viewed as a unique individual with dignity and
worth. The critically ill patient should receive comfort and privacy in a highly technological
environment. In collaboration with other health care team members, critical care nurses provide
high level of patient care which includes patient and family education, health promotion and
rehabilitation. To achieve this holistic care process, participation by the patient and his/her
family is always emphasized. At the forefront of critical care science and technology, critical
care nurses maintain professional competence based on a broad base of knowledge and
experience through continuous education and evidence-based research.
With advances in sophisticated biomedical technology and knowledge, critical care
nurses are able to continuously monitor and observe patients for physiological changes to
confront problems proactively and to assist patients to achieve and maintain an optimum level of
functioning or a peaceful death.
In other words, this nursing philosophy of the CCNAPI is accomplished by looking after
critically ill patient in an environment with specially trained nurses, appropriate equipment,
adequate medical supplies and auxiliary health care personnel.
GOALS OF CRITICAL CARE NURSING
Critical or intensive care is a complex specialty developed to serve the diverse health care
need of patients (and their families) with actual or potential life threatening conditions. It is
therefore important that a clear statement of what critical care nursing wish to achieve and
provide should be articulated.
Goals of critical care nursing include the following:
 To promote optimal delivery of safe and quality care to the critically ill patients and their
families by providing highly individualized care so that the physiological dysfunction as
well as the psychological stress in the ICU are under control
  To care for the critically ill patients with a holistic approach, considering the patient’s
biological, psychological, cultural and spiritual dimensions regardless of diagnosis or
clinical setting.
 To use appropriate and up-to-date knowledge, caring attitude and clinical skills,
supported by advanced technology for prevention, early detection and treatment of
complications in order to facilitate recovery.
 To provide palliative care to the critically ill patients in situations where their health
status is progressing to unavoidable death, and to help the patients and families to go
through the painful sufferings.
On the whole, critical care nursing should be patient-centered, safe, effective, and efficient. The
nursing interventions are expected to be delivered in a timely and equitable manner.
SCOPE OF CRITICAL CARE NURSING
The scope of critical care nursing is defined by the dynamic interaction of the critically ill
patient, the critical care nurse and the critical care environment in order to bring about optimal
patient outcomes through nursing proficiency within an environment conducive to the provision
of this highly specialized care.
Constant intensive assessment, timely critical care interventions and continuous evaluation of
management through multidisciplinary efforts are required to restore stability, prevent
complications and achieve optimal health. Palliative care should be instituted to alleviate pain
and sufferings of the patient and family in situations where death is imminent.
Critical Care Nurses are registered nurses, who are trained and qualified to practice critical
care nursing. They possess the standard critical care nursing competencies in assuming
specialized and expanded roles in caring for the critically ill patients and their family. Likewise,
the critical care nurse is personally responsible and committed to continues learning and
updating of knowledge and skills. The critical care nurses carry out interventions and
collaborates patient care activities to address life-threatening situations that will meet patient’s
biological, psychological, cultural and spiritual needs.
The critical care environment constantly supports the interaction between the critically ill
patients, their family and the critical care nurses to achieve desired patient outcomes. It entails
readily available and accessible emergency equipment, sufficient supplies and effective
supporting system to ensure quality patient care as well as staff safety and productivity.
  
ROLES OF THE CRITICAL CARE NURSES
In response to changes and expansion within and outside the healthcare environment,
critical care nurses have broadened their roles at both practice and advanced practice levels.
Competencies of critical care nurses are honed and developed to achieve their roles as a
practitioner, manager / leader and researcher.
PRACTITIONER ROLE
 ICU nurses execute their practice roles 24-hours a day to provide high quality care to the
critically ill patient.
 1. Care Provider
 Direct patient care
- Detects and interprets indicators that signify the varying conditions of the critically ill
with the assistance of advanced technology and knowledge.
- Plans and initiates nursing process to its full capacity in a need-driven and proactive
manner.
- Acts promptly and judiciously to prevent or halt deterioration when conditions
warrant.
- Co-ordinates with other healthcare providers in the provision of optimal care to
achieve the best possible outcomes.

 Indirect patient care – Care of the Family

- Understands family needs and provide information to allay fears and anxieties.
- Assists family to cope with the life-threatening situation and/or patient’s impending
death.
2. Extended Roles as critical care nurses
- Critical care nurses have roles beyond their professional boundary. With proper
training and established guidelines, algorithms, and protocols that are continuously
reviewed and updated, critical care nurses also perform procedures and therapies that
are otherwise done by doctors.
Such procedures and therapies are:
1. Sampling and analyzing arterial blood gases;
2. Weaning patients off ventilations;
3. Adjusting intravenous analgesia / sedations;
4. Performing and interpreting ECGs;
5. Titrating intravenous and central line medicated infusion and nutrition support; and
6. Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular
tachycardia.
7. Removal of pacer wire, femoral sheaths and chest tubes
8. Other procedures deemed necessary by their respective institution under a clinical
protocol.

3. Educator
 Provides health education to patient and family to promote understanding and
acceptance of the disease process and to facilitate recovery.
 Participates in the training and coaching of novice healthcare team members to
achieve cohesiveness in the delivery of patient care.

4. Patient Advocate
 Acts in the best interest of the patient.
 Monitors and safeguards the quality of care which the patient receives.
MANAGEMENT AND LEADERSHIP ROLE
The critical care nurse in her management and leadership role will be able to render the
following responsibilities:
1. Perform management and leadership skills in providing safe and quality care
2. Accountability for safe critical care nursing practice
3. Delivery of effective health programs and services to critically-ill patients in the acute
setting
4. Management of the critical care nursing unit or acute care setting
5. Take lead and supervision among nursing support staff
6. Utilize appropriate mechanism for collaboration, networking, linkage –building and
referrals.

RESEARCHER ROLE                                                                                   

The critical care nurse in her researcher role will be able to render the following responsibilities:
1. Engage self in nursing or other health –related research with or under supervision of an
experienced researcher.
2. Utilize guidelines in the evaluation of research study or report
3. Apply the research process in improving patient care infusing concepts of quality
improvement and in partnership with other team-players

Advanced Practice Level

This is the future direction in the Philippines and to be benched marked with other
countries. For now, a thorough study of Advanced Practice Nursing in critical care will be
pursued to align with the BON initiative on specialization framework.
 The current healthcare environment demands intensive care nurses to have advanced
knowledge and skills to provide the highest possible level of care to the critically ill patients.
Expanded Roles
1. Nurse Specialist / Clinical Nurse Specialist
Typically, the education and preparation of the critical care nurse practitioner is provided
by the respective hospital or institution without advanced educational preparation beyond that of
the basic baccalaureate degree. Advanced educational preparation refers to the care nursing
training program run by the university or Institute offering Advanced Nursing Studies or other
recognized critical care program both local and overseas.
A registered nurse, who is a nursing degree holder, should have more than more than
years of uninterrupted practice experience in the critical care field and has attained advanced
education and expertise in caring patients with critical problems can function as a critical care
nurse specialist. He /She is also eligible to be accredited by the PRC- Board of Nursing as a
Clinical Nurse Specialist. The Hospital Authority supports this accreditation.
The critical care nurse specialist is responsible for building up nursing competencies in
the ICU entity. He / She contributes to continuous improvement in critical care nursing through
staff and clients education and uphold quality nursing guidelines and patient care through clinical
research and refinement of ICU standards.

2. Advanced Practice Nurse

Advanced Practice Nurse (APN) in the critical care unit takes lead in developing practices to
meet changing clinical needs and to facilitate patient care processes across professional and
organizational boundaries. He /She should have the recommended number of post registration
nursing experience, which are spent in the critical care field, exhibiting in-depth professional
knowledge and skills. An APN (Critical Care) is a holder of a) clinical master degree in a clinical
nursing specialty (Medical-Surgical) such as Critical Care Nursing OR b) master degree in
nursing or related discipline / management together with recognized critical care training
qualification(s). The Advanced Practice Nurse executes the nursing team leader’s responsibilities
as designated in the position of APN (NO) or APN (Ward/Unit Management).

3. Outcomes Manager
Outcome management has been introduced into the healthcare system to ensure achievement of
quality and cost-effectiveness in the delivery of patient care. Some critical care units have
adopted clinical pathways (e.g., Critical Pathways, Protocols, Algorithms and Orders) in the
management of specific diseases such as Acute Myocardial Infarction and Cardio-thoracic
Surgeries. Qualified nurse experts are involved in the development and implementation of
patient outcomes management.
Challenges that critical nurses will face:
The challenging needs from the critical care nursing service and its environments demand the
nurses:
1. To develop, foster and maintain a level of knowledge about the norms, values, beliefs,
patterns of ill health and care needs of the people;
2. To analyze and evaluate specialist skills and criticize their evolving roles;
3. To review current studies and researches and to examine contextual issues thus enabling
evaluation and synthesis of new knowledge, traditional techniques, religious and cultural
influences to be applied in nursing practice, particularly, evidence-based nursing practice;
and
4. To exercise professional judgments expected of them in the critical care clinical setting.
 
TRAINING OF NURSES FOR CRITICAL CARE SERVICES
The institution / hospital should provide training opportunities to ensure staff
competencies. This will enable the nurses working in the critical care units to cope with the
complexities and demands of the changing needs of the critically ill patients. The following
training activities should be supported in order to maintain a high standard of care:
Orientation program / Preceptorship and mentoring program
 New recruits to the critical care shall attend an orientation program and be given the
opportunities to work under supervision. Experienced staff in the unit should be readily
available for consultation.

In-service training program

1. Unit / hospital based training courses / workshop / seminar at hospital level
2. On-the-job training and bedside supervision

Critical Care Nursing Program (Post-Graduate specialty program)

1. Post-graduate Course in Critical Care Nursing / Cardiac Special Care Nursing / Cardiac
Intensive Care Nursing shall be reviewed, evaluated and endorsed to PRC-BON by the
CRITICAL CARE NURSES ASSOCIATION OF THE PHILIPPINES, INC for
accreditation
 Advanced Critical Care Nursing (ACCN) Provider Course
1. It is recommended that the WFCCN policy statement of education shall be used as a
framework for designing a critical care program.

Continuing Nursing Education

 1. CCNAPI recommends that all practicing CCN shall ensure that they continuously update
their knowledge, skills and behavior through active participation in related critical care
nursing education.
 This shall include but not limited to the following adult and pediatric concepts on:
1. Advanced Cardiac Life Support
2. Basic Critical Care Course (BCCC)
3. Cardiac Assessment
4. Neurological Assessment
5. Respiratory Assessment
6. Continuous Renal Replacement Therapy
7. Advanced Pharmacology
8. Advanced Intravenous Therapy
9. Others as may be deemed necessary to enhance critical care practice

LEVELS & CATEGORIES OF CRITICAL CARE PROVISIONS WITHIN

PHILIPPINES
With respect to the physical set-up and supporting facilities of critical care units in the
Philippines, the Department of Health (DOH) Standards requires the critical care units / intensive
care unit to be a self-contained area, with the provisions for resources that will support critical
care practice. Currently, the DOH is reviewing these standards to come-up with updated
requirement.
Sometime in 2003, the Philippine Society of Critical Care Medicine (PSCCM), Society of
Pediatric Critical Care Medicine (SPCCM) and the CCNAPI stratified into different levels and
categories the care provisions in critical care practice to make it similar to its counterparts
overseas with the goal of having effective utilization and organization of resources. Hence, as a
guide, CCNAPI will incorporate these standards into this guideline.
Levels of Care provision
The role of a particular critical care unit will vary, depending on staffing, facilities and
support services as well as the type and number of patients it has to manage. Taking into account
the guidelines of the Society of Critical Care Medicine, the critical care service provision in
Philippines can be classified into 3 levels:
Level 1
 Should be capable of providing immediate resuscitation for the critically ill and short
term cardio-respiratory support because the patients are at risk of deterioration;
 Has a major role in monitoring and preventing complications in “at risk” medical and
surgical patients;
 Must be capable of providing mechanical ventilation and simple invasive cardiovascular
monitoring;
  Has a formal organization of medical staff and at least one registered medical officer
available to the unit at all times;
 A certain number of nurses including the nurse in-charge of the unit should possess post-
registration qualification in critical care or in the related clinical specialties; and
 Has a nurse: patient ratio of 1:1 for all critically ill patients.
Level 2
 Should be capable of providing a high standard of general critical care for patients who
are stepping down from higher levels of care or requiring single organ support/support
post-operatively;
 Capable of providing sustainable support for mechanical ventilation, renal replacement
therapy, invasive hemodynamic monitoring and equipment for critically ill patients of
various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery;
 Has a designated medical director with appropriate intensive care qualification and a duty
specialist available exclusively to the unit at all times;
 The nurse in-charge and a significant number of nursing staff in the unit have critical care
certification; and
 A nurse: patient ratio is 1:1 for all critically ill patients.
Level 3
 Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This
does not only include the management of patients requiring advanced respiratory support
but also patients with multi-organ failure);
 Has a medical director with specialist critical / intensive care qualification and a duty
specialist available exclusively to the unit and medical staff with an appropriate level of
experience present in the unit at all times;
 A nurse in-charge and the majority of nursing staff have intensive care certification; and
 A nurse: patient ratio is at least 1:1 for all patients at all times.
Categories of Critical Care Unit
The Critical Care Unit can be categorized according to patients’ age group or medical specialties.
1. Age group
 Neonatal
 Pediatric
 Adult
2. Specialty
In the existing environment, majority of the Critical Care Units in the Philippines provide
service for patients of various specialties. They are labeled as General ICUs. In certain hospitals,
the critical care unit / service is dedicated to the following specific groups:
1.
 Medical
  Surgical
 Cardio-thoracic
 Cardiac
 Respiratory
 Neurosurgical
 Trauma
 System operation of Critical Care Units
The operation of critical care units can be classified into Open System and Closed System.
1. Open System
The admitting and other attending doctors dictate management, change management or
perform procedures without consultation or communication with a Critical Care Specialist. A
Critical Care Specialist may be available for advice or be consulted to provide interventional
skills (optional). No one designated person assumes the “gatekeeper” role.
2. Closed System
Management is coordinated by a qualified Critical Care Specialist. The critical / intensive
care specialist has clinical and administrative responsibility.
There is a multi-disciplinary team of specially trained critical care staff. The “intensivist”
is the final common pathway for all medical decision-making including the decision to admit or
discharge.
Irrespective of the ICU “System” Operation, i.e. open system or closed system, or a
mixture of the two, there should be a designated group of registered nurses under a unique
management to provide highly specialized care to the critically ill patients. The nurse in-charge
and the majority of nursing staff in each unit should have the relevant qualification in the
specialty of the respective Unit.
Critical Care Nursing Workforce
The CCNAPI will adopt the Position Statement of the World Federation of Critical Care
Nurses on the Provisions of Critical Care Nursing Workforce also called the Declaration of
Buenos Aires ratified in the full council meeting last August 27, 2011 at the Sheraton Hotel,
Buenos Aires, Argentina.
The declaration presents guidelines universally accepted by critical care professionals,
which may be adapted to meet the critical care nursing workforce and system requirements of a
particular country or jurisdiction. The declaration states the specific central principles governing
the provision and provides for specific recommended critical care nursing workforce
requirement. The complete declaration is attached as Annex to this guideline.
COMPETENCIES FOR CRITICAL CARE NURSES
The competence of critical care nurses together with established nursing standards and
the identified core competencies for registered nurses will result to excellence in critical care
nursing practice. This three pronged holistic framework ensures quality performance through an
 adherence to nursing standards, the application of competencies, and the integration of
appropriate nursing model/s into the care delivery process.
To achieve safe and quality client-centered care, nurses working in the critical care units
are envisioned to adopt not only the stated core competencies of registered nurses but also the
specific competencies stipulated in the following eleven major key responsibility areas:
1.       Safe and Quality Nursing Care
1. Conducting nursing assessment
Ø  The critical care (ICU) nurse performs patient health assessment accurately, continuously,
comprehensively and systematically. The critical care nurse prioritizes the health needs of
the patient from a holistic perspective.
 
2. Formulating care plans
Ø  The critical care nurse develops individualized, holistic and patient-centered care plans that
document nursing diagnoses / identifies patient’s problems in relation to patient’s needs.
3. Implementing planned care
Ø  The critical care nurse implements planned care to achieve optimal health status of
dignified death of the patient.
4. Evaluating patient’s health progress and outcome
Ø  The critical care nurse evaluates the outcomes of nursing care in an explicit, systematic and
ongoing manner.
5. Maintaining effective communication
Ø  The critical care nurse communicates relevant, accurate and comprehensive information,
both verbal and written, about the patient’s health status to related health care team
members and family members.
6. Acting in emergency situations such as rapid deterioration, life- threatening, unstable,
and critical events
Ø  The critical care nurse responds swiftly in a calm and proficient manner when faced with
an unexpected or rapidly changing situation related to the patient or environment.
7. Demonstrating specific knowledge and skills in the critical care setting
Ø  The critical care nurse provides quality and effective care to patient in the following
aspects:
Pulmonary
Cardiovascular
Neurological
 Renal
Gastrointestinal
Endocrine
Peri-operative
 
2.       Management of Resources
1. Managing within the organization
Ø  The critical care nurse understands the mission and core values of the organization and
facilitates the achievement of the organizational goals.
2. Empowering subordinates
Ø  The critical care nurse achieves targets through subordinates using the processes and
techniques associated with motivating, coaching, delegating and supervising.
3. Assisting in maintaining a safe and healthy working environment
Ø  The critical care nurse carries out activities to assist in maintaining a favorable working
environment
 
3.       Legal Responsibilities
Fulfilling legal responsibilities and acting as patients advocate
Ø  The critical care nurse functions in accordance with common law, ordinance and regulations
influencing nursing practice.
 
4.        Ethico-Moral Responsibilities
Practicing ethico-moral standards of the nursing profession.
Ø  The critical care nurse demonstrates the appropriate application of knowledge in nursing
practice, which complies with the code of professional conduct, principles of autonomy,
beneficence and justice. She / He also accepts personal responsibility for one’s own
professional judgments and actions as well as consequence of one’s behavior
 
5.       Collaboration and Teamwork
1. Maintaining collaborative relationships in the multi-disciplinary team
Ø  The critical care nurse maintains collaborative relationships within the ICU team. This
relationship contributes towards the achievement of smooth and effective team performance in
accomplishing common goals.
 2. Maintaining a cohesive nursing team
Ø  The critical care nurse establishes and maintains harmonious working relationships with
nursing colleagues
 
6.        Personal and Professional Development
1. Facilitating the development of nursing knowledge in clinical setting
Ø  The critical care nurse takes initiative to support or conduct activities, which promote the
advancement of nursing knowledge
2. Promoting the professional image of ICU nurse
Ø  The critical care nurse acts in manner that maintains active ongoing involvement in activities
related to the nursing profession such as ICU conference, workshop and course; and promotes
the professional image of nursing.
Evaluating own nursing practice and knowledge to enhance personal skills
Ø  The critical care nurse assesses self-awareness of his/her own professional competence
continuously and independently; maintains up-todate nursing knowledge to keep abreast of
nursing trends and nursing standards in specialty practice.
 
7.       Communication
Communicates with individual patient and/or groups and with other members of the health
care team
Ø  The critical care nurse takes initiative to communicate with individual and / or groups and with
other members of the health team to facilitate care and management of the patients
 
8.       Health Education
Provides appropriate health education based on comprehensive learning needs of the patient
and family
Ø  The critical care nurse makes thorough assessment of the learning needs of the patient and
family for the provision of health education to assist the patient and family towards a
productive life
 
9.       Quality Improvement
Proactive in the implementation of changes as a consequence of quality improvement
initiatives
Ø  The critical care nurse demonstrates positive attitudes towards change for improvement
  

10.       Research
Supports a positive climate for research within the practice setting
Ø  The critical care nurse maintains currency of knowledge and practice based on relevant
research findings
 
11.       Record Management
Ensures that written information conforms to legal and ethical framework
Ø  The critical care nurse maintains accurate and updated documentation of the care for the
critically ill patients
 
STANDARDS OF CRITICAL CARE NURSING PRACTICE
Critical care specialty addresses the management and support of patients with severe or
life-threatening illness. The goal of critical care nursing is to promote optimal adaptation of
critically ill patients and their families by providing highly individualized care, so that the
critically ill patients adapt to their physiological dysfunction as well as the psychological stress
in the Critical Care Unit or Intensive Care Unit (ICU). In order to achieve this, standards should
be developed to serve as a guide for monitoring and enhancing the quality of intensive care
nursing practice.
Care standards for critical care nursing provides measures for determining the quality of
care delivered, and also serves as means for recognizing the competencies of nurses in intensive
care specialty.
Procedures standards for critical care nursing practice provide a step-by-step guideline in
guiding nurses to carry out day-to-day nursing procedure in a most appropriate manner.
The following 11 are Standards are intended to furnish nurses with direction in providing quality
care and excellence in Critical Care Nursing.
1. The critical care nurse functions in accordance with legislation, common laws,
organizational regulations and by-laws, which affect nursing practice.
2. The critical care nurse provides care to meet individual patient needs on a 24-hour basis.
3. The critical care nurse practices current critical care nursing competently.
4. The critical care nurse delivers nursing care in a way that can be ethically justified.
5. The critical care nurse demonstrates accountability for his/her professional judgment and
actions.
6. The critical care nurse creates and maintains an environment which promotes safety and
security of patients, visitors and staff.
 7. The critical care nurse masters the use of all essential equipment, available services and
supplies for immediate care of patients.
8. The critical care nurse protects patients from developing environmental induced
infection.
9. The critical care nurse utilizes the nursing process in an explicit systematic manner to
achieve the goals of care.
10. The critical care nurse carries out health education for promotion and maintenance of
health.
11. The critical care nurse acts to enhance the professional development of self and others.
 
Patient Safety in Critical Care
Creating a Culture of Safety in Critical Care
It is intuitive to think that the ICU would be one of the safest places within the hospital
environment. However, the reverse is often true. A recent multinational study found that on
average 38.8 sentinel events occur per 100 patient ICU days.  The genesis for these sentinel
events revolve around two separate but intertwined factors: the complex interactions between
medical/nursing/technician healthcare professionals and therapeutic intervention per disease
entity. The complexity of care within the ICU requires that healthcare professionals exhibit a
trans-disciplinary level of competency.  This has lead critical care teams to embrace evidence-
based guidelines, which encourage the use of standardized process measures for managing ICU
patient populations. For example, the concept of the “Care Bundle,” aggregated evidence-based
interventional practices has reduced the risk of central line-associated blood stream infections
(CLABSIs), ventilator-associated pneumonia (VAP), deep vein thrombosis (DVT) and stress
ulcers, frequent hospital acquired conditions.
Implementing Evidence-Based Process Measures – Promoting Effective Infection Control
Initiatives
“Care Bundles”
The concept of the “care bundle” has become central to mitigating the risk of healthcare-
associated infections within the ICU environment. The “care bundle” was developed in an effort
to move away from dependency on individual knowledge, motivation and skills, focusing instead
on a systematic approach for delivering structured care. The “care bundle” is composed of a
series of separate but inter-related elements that flow in a cohesive manner and is validated
(evidence-based) as improving patient outcomes. An interesting observation in the development
of an early care bundle to reduce the risk of ventilator- associated pneumonia found that the
process as designed did not immediately results in decrease risk of VAP in a trauma unit. It was
only after a process tool was put into place that measured daily compliance to the bundle did the
rate of VAP actual decline in the trauma ICU.
While evidence-based medicine has been a guiding factor in the development of “care
bundles” in the ICU, it should be recognized that evidence-based practice is a moving target and
that therefore these interventions must evolve over time.  Whereas in the original IHI VAP
bundle, stress ulcer prophylaxis was a prominent component of the bundle package, subsequent
iterations have omitted this element of the package, substituting instead subglottic suctioning as
new evidence emerges validating efficacy. As these processes becomes standardized in the ICU,
compliance rates should be in the 90% to 100% range. A high level of compliance to process
measures such as the ventilator bundle or central line bundle have been documented in the
literature to improve patient outcomes by reducing morbidity and mortality. Unfortunately, this
has not been the case with all recent process initiatives, a case in point is the Surgical Care
Improvement Project. High compliance to the SCIP core process measures has resulted in mixed
reviews with some reports documenting little of no decrease in the rate of SSI while others have
observed an increased SSI in the present of high compliance. The complexities of surgical
interventions, patient morbidities and variations in surgical technique all challenge the concept of
process standardization, especially in the postoperative patient who end up in the intensive care
unit.  However, the convergence of scientific inquiry, public perception and legislative initiatives
has targeted HAIs as a patient safety issue thereby creating a national momentum necessary for
improving patient outcomes within a “culture of safety.”
Hand Hygiene
Hand washing, while considered the cornerstone for disrupting the transmission of
healthcare-associated pathogens, the strength of its’ scientific efficacy (the best way to do it) has
produced mixed results. There is no argument that the hands of all healthcare workers become
contaminated during the execution of their duties and that this contamination can be transferred
via contact to inert surfaces or other patients and/or staff members. Unfortunately, the current
educational efforts aimed at improving hand hygiene tend to focus on personal consequence
rather than patient consequences, a classic disconnect. Failure to practice appropriate hand
hygiene creates an endangerment not necessarily to self but to that, “next individual who you
will be caring for.”
Imaging Safety and Intrahospital Transportation
Radiologic imaging of patients in the ICU is a universal event, and while a number of
studies can be performed at the bedside, transport to another department for routine imaging and
image-guided procedures may be required for a large number of patients.  Mazza et al
documented a 32.4% complication rate in patients transported out of the ICU for imaging
studies, while most of the imaging studies obtained were for “follow up” of a previously
documented abnormality.  Complications included agitation, hypotension, hypoxemia, and
hypertension with no patient deaths.  While other patients in this study suffered only changes in
their arterial blood gas parameters that were not clinically significant, other authors have
documented multiple complications due to transport for imaging studies and other procedures,
including death directly attributed to this practice.  An earlier study on the subject demonstrated
a 75% complication rate (hypotension and hypercarbia) in patients being transported for
radiologic studies using a manual ventilation system, compared to a 44% rate of the same
complications in patients transported with a transport ventilator. Another published series of
patients being transported for imaging revealed deaths and severe morbidity related to transport
and documented other significant complications, such as a drain being removed after being
caught in a doorway.  In 1990, Smith et al demonstrated a 60% complication rate for patient
transport out of the ICU for elective procedures, compared to 40% for patients being transported
for emergency procedures.  An informative retrospective analysis in 1988 demonstrated a 68%
rate of complications directly related to transport of trauma patients out of the ICU for imaging
studies, and surprisingly revealed that 76% of all studies obtained had no influence on patient
management. Similar results have been reported by other authors. A multidisciplinary transport
team can reduce the risks associated with these “road trips”.  Given the volume of literature
documenting a large number of complications related to intrahospital transport of critically ill
patients, substantial consideration of the potential for a study to alter patient management should
be undertaken prior to sending a patient out of the tightly controlled ICU environment for
imaging.  Bedside imaging and image-guided procedures provide an alternative to transport for
radiologic studies in critically ill patients.  Examples include portable chest radiography, lung
ultrasound, renal ultrasound, and bedside placement of central venous access catheters and
inferior vena cava filters.
The portable chest x-ray (pCXR) is a mainstay of critical care.  As with any other bedside
procedure, pCXR entails some amount of risk for dislodging monitoring devices, endotracheal
tubes and invasive monitoring devices, along with ergonomic risk to nursing and technical staff
that have to reposition the patient. 
Device Safety
The use of medical devices for monitoring, whether invasive or non-invasive, is
ubiquitous in the ICU setting.  Errors in the use of these devices can range from improperly set
alarms leading to detrimental outcomes from unrecognized complication( such as prolonged
periods of unrecognized abnormal cardiac rhythms), to accidental removal of life-sustaining
devices such as endotracheal tubes and intraaortic balloon pumps.
As device criticality increases, so often does complexity of use.  Unfortunately, devices
that are more complex and more critical to sustaining life are often used rarely, with a
corresponding increase in possibility for errors. In addition, the overall level of congestion of
instruments, wires, intravenous lines, and monitors around the ICU patient has been shown to
contribute to the number of errors in their care, with up to 30% of errors considered severe
enough to potentially cause harm or death.  Clearly improvement of the ergonomic environment
of the ICU, along with improvement of device interfaces at all levels, is critical to improvement
of patient safety in the future and a necessary direction of future research.
Ethical & Legal Decisions in Critical Care Units
Ethical Standards
 Based on human principle of right & wrong Legal Standards
 Based on written law
Ethical Decision Making
 Emerged in the recent years as a major component of health care for the critically ill
patients.
 Refers to the process of evaluating and choosing among alternatives in a manner
consistent with ethical principles.
Ethical principles
Autonomy
 Patient’s right to self determination.
Non-maleficent
 do no harm
  Beneficence
 promoting good
Veracity
 the obligation to tell the truth
Fidelity
 faithfulness to agreements & responsibilities
Justice
 the fair allocation of medical resources.
Ethical Dilemmas Experienced by Nurses Working in Critical Care Units:
 Identified “end-of-life decisions, Patient care issues and human rights issues” as the
emerging ethical issues.
 In resolving the dilemmas most of the participants indicated that they would report the
issues to the physician.
Ethical Decisions End-of-life Issues
 Palliative Care
o caring for a patient to relieve pain and make the dying process as peaceful as it
can be.
o Depending on patients' wishes, they are given food and hydration.

 CPR decisions
o Ethical questions on CPR: in what situations, for how long?
o Do not resuscitate(DNR): orders are commonly implemented in the critical care
setting as a prelude to end-of-life care.

 Euthanasia
- a Greek word meaning “good death,” is popularly known as “mercy killing.”
 Active euthanasia
  Passive euthanasia

 Withholding & withdrawing treatment

o Withholding: never initiating a treatment
o Withdrawing: to stop a treatment once started
o Best made after careful discussion (health care professional, patient and family)
 Futile care
o Futile medical care is the continued provision of medical care or treatment to a
patient when there is no reasonable hope of a cure or benefit.
Perceptions of “futile care” among caregivers in intensive care units
 Respondents felt that futile care was provided because of family demands, a lack of
timely or skilled communication, or a lack of consensus among the treating team.
Practical Principles for Ethical decision making
 Identify source of authority for decision making.
 Achieve effective communication with patient and families
 Carry out early determination and ongoing review of patient’s desire.
 Clearly recognize patient’s rights.
 Carry out hospital policies.
 Protect the nurse’s own standards of care.
Recommendations for end-of-life care in the intensive care unit:
 A consensus statement by the American College of Critical Care Medicine
 Concluded that End-of-life care is emerging as a comprehensive area of expertise in the
ICU & highlighted the importance of shared decision making and the importance of
caring for patients’ families
Legal decisions in critical care units
Medical Documentation
1. Informed Consent
  In order to be considered legally effective, consent to medical treatment must meet three
tests:

o voluntary
o adequately informed or knowing.
o given by an individual with adequate mental capacity and legal authority.

2. Advance directives
 is a document by which a person makes provision for health care decisions in the event
that, in the future, he/she becomes unable to make those decisions.
 These directives may also designate a specific surrogate decision maker who then has
ethical and possibly legal standing to make medical decisions for the patient.

3. . Incident reports
 Document the occurrence of anything out of the ordinary that results in, or has the
potential result in, harm to a patient, employee or visitor.
 The nurse responsible for a potentially or actually harmful incident or who witnesses an
injury is the one who fills out the incident form.
Other Important legal documents
 Consultations & referral slips
 Nurses record
 Treatment and investigation record
 TPR chart, BP monitoring chart, IO chart/ Progress report
 Operative notes
 Discharge summary
 Death certificate
Use of Restraints
 Intervention that limits a person’s freedom to move
 Physical or chemical.
 Use only when all other methods have failed
 as a last resort
 use least restrictive method possible
Nurses’ related factors influencing the use of physical restraint in critical care units
 it can be concluded that those older nurses and those with higher qualification and
years of experience have better performance than others.
 Nurses’ knowledge and performance are in need for improvement
Declaring Brain death
 Require a physician not involved in the patient treatment to document brain death and
another physician to confirm the findings
 3 essential findings in brain death are coma, absence of brainstem reflexes, and apnea.

Passive euthanasia
Organ donation Decision
 The donation can be made by a provision in a will or by signing a card- like form.
 Nurses may serve as witnesses for people consenting to donate organs.
Autopsy
 An autopsy or postmortem examination is an examination of the body after death.
 The law describes under what circumstances an autopsy must be performed, for
example, all Medico-Legal Cases should undergo autopsy.

SCOPE OF NURSING PRACTICE

(stipulated in Article VI Sec. 28 of R.A. 9173, otherwise known as “The Philippine Nursing
Act of 2002.”)
Republic Act No. 9173 October 21, 2002
AN ACT PROVIDING FOR A MORE RESPONSIVE NURSING PROFESSION,
REPEALING FOR THE PURPOSE REPUBLIC ACT NO. 7164, OTHERWISE KNOWN
AS "THE PHILIPPINE NURSING ACT OF 1991" AND FOR OTHER PURPOSES
ARTICLE VI
Nursing Practice
Section 28. Scope of Nursing. - A person shall be deemed to be practicing nursing within
the meaning of this Act when he/she singly or in collaboration with another, initiates and
performs nursing services to individuals, families and communities in any health care setting.
It includes, but not limited to, nursing care during conception, labor, delivery, infancy,
childhood, toddler, preschool, school age, adolescence, adulthood, and old age. As
independent practitioners, nurses are primarily responsible for the promotion of health and
prevention of illness. As members of the health team, nurses shall collaborate with other
health care providers for the curative, preventive, and rehabilitative aspects of care,
restoration of health, alleviation of suffering, and when recovery is not possible, towards a
peaceful death. It shall be the duty of the nurse to:
(a) Provide nursing care through the utilization of the nursing process. Nursing care includes,
but not limited to, traditional and innovative approaches, therapeutic use of self, executing
health care techniques and procedures, essential primary health care, comfort measures,
health teachings, and administration of written prescription for treatment, therapies, oral
topical and parenteral medications, internal examination during labor in the absence of
antenatal bleeding and delivery. In case of suturing of perineal laceration, special training
shall be provided according to protocol established;
(b) Establish linkages with community resources and coordination with the health team;
(c) Provide health education to individuals, families and communities;
(d) Teach, guide and supervise students in nursing education programs including the
administration of nursing services in varied settings such as hospitals and clinics; undertake
consultation services; engage in such activities that require the utilization of knowledge and
decision-making skills of a registered nurse; and
(e) Undertake nursing and health human resource development training and research, which
shall include, but not limited to, the development of advance nursing practice;
Provided, That this section shall not apply to nursing students who perform nursing
functions under the direct supervision of a qualified faculty: Provided, further, That in the
practice of nursing in all settings, the nurse is duty-bound to observe the Code of Ethics for
nurses and uphold the standards of safe nursing practice. The nurse is required to maintain
competence by continual learning through continuing professional education to be provided
by the accredited professional organization or any recognized professional nursing
organization: Provided, finally, that the program and activity for the continuing professional
education shall be submitted to and approved by the Board.
Patient’s Bill of  Rights

1. Right to Good Quality Health Care and Humane Treatment - Every person has a right
to a continuity of good quality Health Care without discrimination and within the
limits of the resources, manpower and competence available for health and medical
care. In the course of such care, his human dignity, convictions, integrity, individual
needs and culture shall be respected.
If a Patient cannot immediately be given treatment that is medically necessary, he shall
be informed of the reason for the delay and be treated in accordance with his best interests,
Provided, that the treatment applied shall be in accordance with generally accepted medical
principles.
Emergency Patients shall be extended immediate medical care and treatment without
requiring, as a prerequisite thereof, any pecuniary consideration.
1. Right to Dignity - The Patient's dignity, culture and value shall be respected at all
times in medical care and teaching. Likewise, terminally ill patients shall be entitled
to humane terminal care to make dying as dignified and comfortable as possible.
2. Right to be Informed of His Rights and Obligations as a Patient - Every person has
the right to be informed of his rights and obligations as a Patient. In line with this, the
Department of Health, in coordination with Health Care Providers, professional and
civic groups, the media, health insurance corporations, people’s organizations and
local government organizations, shall launch and sustain a nationwide information
 and education campaign to make known to the people their rights as Patients, as
provided in this Act. It shall also be the duty of Health Care Institutions to inform
Patients of their rights as well as of the institution’s rules and regulations that apply to
the conduct of the Patient while in the care of such institution. These rights and rules
and regulations shall be posted in a bulletin board conspicuously placed in a Health
Care Institution.
3. Right to Choose His Physician I Health Institution - The Patient is free to choose the
services of a physician or health institution of his choice except when he chooses to
be confined in a charity ward. In this case, the attending physician shall be the
consultant under whose service the patient was admitted as appearing in the Doctor’s
Order Sheet of the Medical Record. The Patient shall have the right to seek a second
opinion and subsequent opinions, if necessary, from another physician or health
institution, and to change his physician or health institution.
4. Right to Informed Consent - The Patient has a right to self-determination and to make
free decisions regarding himself/herself. However, the attending physician shall
inform the Patient of the consequences of his/her decisions. A Patient who is mentally
competent and is of legal age, or in his incapacity or age of minority, his legal
representative, has a right to a clear explanation, in layman’s terms, of all proposed or
contemplated procedures, whether diagnostic or therapeutic, including the identity
and professional circumstances of the person or persons who will perform the said
procedure or procedures. The explanation shall include the amount of information
necessary and indispensable for him to intelligently give his consent, including, but
not limited to, the benefits, risk, side effects and the probability of success or failure,
as a possible consequence of said proposed procedure or procedures, including the
implications of withholding consent. Ion the explanation, the comprehensive ability
of the patient shall also be considered, taking into account his level of education, the
dialect or language that he speaks and understands, and if possible, with the use of
anatomic sketch or any materials or visual aids that may aid the Patient, or his legal
representative, in fully understanding the proposed procedure or procedures.
The right to informed consent shall likewise consider the voluntariness' in which 'the
Patient or his/her legal representative has given his/her consent, seeing to it that the Patient or
his legal representative was allowed to ask questions, or that he/she is given the chance to
consult his/her kin, or to seek another expert opinion. If the Patient is unconscious or is
unable to express his/her will, informed consent must be obtained whenever possible from a
legal representative,
Provided however, That when medical intervention is urgently needed, the consent of the
patient may be presumed, Provided further, That a physician should always try to save the
life of a Patient who is unconscious due to suicide attempt.
In the case of a Patient who is legally incompetent or is a minor, the consent of a legal
representative is required, Provided however, That the Patient must be involved in the
decision making process to the fullest extent allowed by his mental capacity. If the legally
incompetent Patient can make rational decisions, his/her decisions must be respected, and
he/she has the right to forbid disclosure of such information to his/her legal representative.
 If the patient's legal representative forbids treatment, but, in the opinion of the physician,
it is contrary to the patient's best interest, the physician may challenge this decision in court,
Provided however, That in emergency cases, the physician shall act in the patient's best
interest,
Provided further, That in emergency cases where there is no one who can give consent on
the patient's behalf, the physician can perform any emergency diagnostic or treatment
procedure in the best interest of the patient.
1. Right to Refuse Diagnostic and Medical Treatment - The Patient has the right to
refuse diagnostic and medical treatment procedures, provided that the following
conditions are satisfied;
2. The Patient is of legal age and is mentally competent;
3. The Patient is informed of the medical consequences of his/her refusal;
iii. The Patient releases those involved in his care from any obligation relative to the
consequences of his/her decision; and
1. The Patient's refusal will not jeopardize public health and safety.
2. Right to Refuse Participation in Medical Research - The Patient has the right to be
advised of plans to involve him/her in medical research that may affect the care or
treatment of his/her condition. Any proposed research shall be performed only upon
the written informed consent of the Patient.
3. Right to Religious Belief and Assistance - The Patient has the right to receive
spiritual and moral comfort, including the help of a priest or minister of his/her
chosen religion. He/she also has the right to refuse medical treatment or procedures
which may be contrary to his religious beliefs, subject to the limitations described in
paragraph 6 of this Section.
4. Right To Privacy and Confidentiality - The patient has the right to privacy and
protection from unwarranted publicity. The right to privacy shall include the patient's
right not to be subjected to exposure, private or public, either by photography,
publications, video-taping, discussion, or by any other means that would otherwise
tend to reveal his person and identity and the circumstances under which he was, he
is, or he will be, under medical or surgical care or treatment. The Patient and his/her
legal representative has the right to be informed by the physician or his/her legal
representative of the patient's continuing Health Care requirements following
discharge, including instructions about home medications, diet, physical activity and
other pertinent information.
All identifiable information about a patient's health status, medical condition, diagnosis,
prognosis and treatment, and all other information of a personal kind, must be kept
confidential even after death, Provided, That descendants may have a right of access to
information that will inform them of their health risks.
All identifiable Patient data must also be protected. The protection of the data must be
appropriate as to the manner of its storage. Human substance from which identifiable data
can be derived must be likewise protected.
Confidential information can be disclosed in the following cases:
 1. When the patient's medical or physical condition is in controversy in a court litigation
and the court, in its discretion, orders the patient to submit to physical or mental
examination of a physician:
2. When public health or safety so demands;
iii. When the Patient, or in his incapacity, his/her legal representative, expressly gives the
consent;
1. When the patient's medical or surgical condition is discussed in a medical or scientific
forum for expert discussion for his/her benefit or for the advancement of science and
medicine, Provided however, That the identity of the Patient should not be revealed;
and
2. When it is otherwise required by law.
3. Right to Disclosure of, and Access to, Information - In the course of the patient's
treatment and hospital care, the Patient or his/her legal guardian has the right to be
informed of the result of the evaluation of the nature and extent of his/her disease.
Any other additional or further contemplated medical treatment on surgical procedure
or procedures, shall be disclosed and may only be performed with the written consent
of the patient.
The disclosure of information may be withheld if giving the information to the Patient
will cause mental suffering or further impair his health, Provided, That such disclosure may
be withheld or deferred to some future opportune time upon due consultation with the
patient's immediate family, Provided further, That such information must be given in a way
that is appropriate to the local culture and in a manner the Patient can understand. The Patient
has the right to choose who he/she desires should be informed on his behalf, Provided
however, That the Patient also has the right not to be informed on his explicit request, unless
it is required for the protection of another person's life.
The Patient has the right to be given, and examine, an itemized bill for hospital and
medical services rendered. He is entitled to a thorough explanation of such bill.
1. Right to Correspondence and to Receive Visitors - The Patient has the right to
communicate with his/her relatives and other persons and to receive visitors subject to
reasonable limits prescribed by the rules and regulations of the Health Care
Institution.
2. , Right to Medical Records - The Health Care Institution and the physician shall
ensure and safeguard the integrity and authenticity of the medical records.
The Patient, upon his/her request, is entitled to a medical certificate and clinical abstract.
He/she has the right to view, and obtain an explanation of, the contents of his/her medical
records from the attending physician, except for psychiatric notes and other incriminating
information obtained about a third party.
The Patient may also obtain from the Health Care Institution a reproduction, at his/her
expense, of his/her medical records, except for the psychiatric notes and incriminating
evidence referred to above, Provided, That any relevant document that the Patient may
require for insurance claims shall be made available to him within a reasonable period of
time.
 1. Right to Health Education - Every person has the right to health education that will
assist him in making informed choices about personal health and about available
health services. The education shall include information about healthy lifestyles and
about methods of prevention and early detection of illnesses. The personal
responsibility of everybody for his own health should be stressed.
2. Right to Leave Against Medical Advise - The Patient has the right to leave a hospital
or any other Health Care Institution regardless of his physical condition, Provided,
That:
3. He/she is informed of the medical consequences of his/her decision;
4. Hel/she releases those involved in his/her care from any obligation relative to the
consequences of his/her decision; and
iii. His/her decision will not prejudice public health and safety,
1. Right to Express Grievances. - Every Patient has the right to express valid complaints
and grievances about the care and services received and to know the disposition of
such complaints, in accordance with Sections 7-8 of this Act.
Obligations of Patients
1. Know Rights - The Patient shall ensure that he knows and understands what his/her rights
as a Patient are and shall exercise those rights responsibly and reasonably.
2. Provide Adequate, Accurate and Complete Information - The Patient shall provide, to the
best of his/her knowledge, adequate, accurate and complete information about all matters
pertaining to his/her health, including medications and past or present medical problems,
ailments, medical history, consultation with other physicians, results of diagnostic work-
up and treatment, to his/her Health Care Provider.
3. Report Unexpected Health Changes - The Patient shall report unexpected changes to
his/her condition or symptoms, including pain, to his/her Health Care Provider.
4. Understand the Purpose and Cost of Treatment - The Patient shall ensure that he/she
understands the purpose and cost of any proposed treatment or procedure before deciding
to accept it. He/she shall notify his/her Health Care Provider if he/she does not
understand any information about the proposed care or treatment. The Patient shall insist
upon explanations until adequately informed and shall endeavor to make all the necessary
consultations before reaching a decision.
5. Accept the Consequences of Own Informed Consent - The Patient shall accept all the
consequences of his/her own informed consent. If he/she refuses treatment or does not
follow the instructions or advice of the Health Care Provider, he/she must accept the
consequences of such decision and relieve the Health Care Provider of any liability as a
result of the exercise of his/her right to self-determination,
6. Settle Financial Obligations. - The Patient shall ensure that the financial obligations as a
result of his/her Health Care are fulfilled as promptly as possible. Otherwise, he/she shall
make the appropriate arrangements to settle unpaid hospital bills and/or professional fees
in accordance with Republic Act No. 9439. The patient must seek support from the State
in order to establish a system of payment to Health Care Institutions and Providers.
7. Respect the Rights of Health Care Providers, Health Care Institutions and Other Patients -
The Patient is obligated to give due respect to the rights and well-being of Health Care
 Providers, Health Care Institutions and other Patients. He shall act in a considerate and/or
cooperative manner and shall give respect to the rights and properties of others. He shall
follow the policies, rules and regulations, and procedures of Health Care Institutions.
8. Obligation to Self - The Patient shall refrain from indulging in unhealthy food
consumption; addiction forming substance foods such as tobacco, alcohol and drugs;
lifestyles that have an adverse impact on health, such as sexual promiscuity and reckless
activities; and contamination of the environment. The Patient is obligated to maintain a
state of wellness.
9. Provide Adequate Health Information and Actively Participate in His/Her Treatment. -
The Patient shall ensure that he/she has adequate health information that' will allow
him/her to actively participate in the formulation of his/her diagnostic and treatment
plans. When he/she signs an informed consent, it is assumed that he has the necessary
information.
10. Respect the Right to Privacy of Health Care Providers and Institutions. - The Patient has
the obligation to submit grievances to the proper authorities or venue and not resort to
unwarranted publicity in the media. He/she shall not disclose to the public any alleged
complaint 12 against Health Care Providers and/or Institutions if it has not been fully
decided by a court or administrative tribunal of prosper jurisdiction.
11. Exercise Fidelity on Privileged Communication - A patient-physician relationship is a
fiduciary one where mutual trust, respect and confidence are expected. All
communications are privileged and the patient is obliged not to breach this privileged
communication especially if it involves a third party.
12. Respect a Physician’s Refusal to Treat Him - While the Patient has the right to choose
his/her physician, he/she is also obligated to respect the physician’s decision to choose
whom he/she will treat.
13. Respect the Physician’s Decision on Medical Reasons based on His/Her Religious
Beliefs - The Patient is obliged to respect the physician’s religious beliefs. If the Patient
is a minor or is legally incapacitated, his/her parents or legal representatives are obliged
to likewise respect the physician’s decision on matters relating to medical reasons despite
their religious beliefs.
14. Ensure Integrity and Authenticity of Medical Records - The Patient is obliged to ensure
the integrity and authenticity of his/her medical records. Any manner of alteration of
his/her records is a criminal offense subject to the provisions of the Revised Penal Code.
15. Participate in the Training of Competent Future Physicians - The Patient is obligated to
participate in the training of future physicians provided that necessary information is
provided to him/her and the appropriate ethical considerations are observed.
16. Report Infractions and Exhaust Grievance Mechanism. - The Patient shall immediately
inform his/her Health Care Provider of any perceived or alleged infraction of his/her
rights as set forth in this Act through proper channels in order to promote mutual trust,
respect and confidence between the Provider and the and Patient. The Patient shall
exhaust the 13 grievance mechanism mediation provided in Sections 7-8 of this Act
before filing any administrative or legal action.
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