1

Prof. Dr. Ram Shran Mehta

Ethical & Legal Decisions
in Critical Care Units
Learning Objectives 2

Prof. Dr. Ram Shran Mehta

At the end of the seminar participants
will be able to:
 Distinguish between ethical and legal
standards.
 Review ethical principles.
 Discuss common ethical dilemmas and
decision.
 Discuss the common legal decision in
critical care units.
 3

Prof. Dr. Ram Shran Mehta

Ethical Legal Standards
Standards
• Based on • Based on
human written law
principle of
right & wrong
Ethical Decision Making 4

Prof. Dr. Ram Shran Mehta

 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.
 • the fair allocation of medical Justice
resources.
• faithfulness to agreements & Fidelity
responsibilities
• the obligation to tell the truth.
Veracity
• promoting good
Beneficence
• do no harm.
Non-maleficent

Prof. Dr. Ram Shran Mehta

• Patient’s right to self Autonomy
determination.
5
Ethical principles
 Ethical Dilemmas Experienced by 6
Nurses Working in Critical Care

Prof. Dr. Ram Shran Mehta

Units in Kenyatta National Hospital

 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.
 7
Ethical Decisions

Prof. Dr. Ram Shran Mehta

End-of-life Issues
• Palliative Care
• CPR decisions
• Euthanasia
• Withholding & withdrawing treatment
• Futile care
Practical Principles for 8
Ethical decision making

Prof. Dr. Ram Shran Mehta

 Identify source of authority for decision
making.
 Achieve effective communication with
patient and families
Practical Principles for 9

Ethical decision making

Prof. Dr. Ram Shran Mehta

 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 10
the intensive care unit: A consensus
statement by the American College of

Prof. Dr. Ram Shran Mehta

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
Palliative care 11

Prof. Dr. Ram Shran Mehta

 caring for a patient to relieve pain and
make the dying process as peaceful as it
can be.
 Depending on patients' wishes, they are
given food and hydration.
CPR Decisions 12

Prof. Dr. Ram Shran Mehta

 Ethical questions on CPR: in what
situations, for how long?
 Do not resuscitate(DNR): orders are
commonly implemented in the critical
care setting as a prelude to end-of-life
care.
Euthanasia 13

Prof. Dr. Ram Shran Mehta

 Euthanasia, a Greek word meaning
“good death,” is popularly known as
“mercy killing.”
 Active euthanasia
 Passive euthanasia
Withholding or 14

withdrawal of life support

Prof. Dr. Ram Shran Mehta

 Withholding: never
initiating a treatment
 Withdrawing: to stop a
treatment once started
 Best made after careful
discussion (health care
professional, patient and
family)
Futile care 15

Prof. Dr. Ram Shran Mehta

 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” 16
among caregivers in intensive

Prof. Dr. Ram Shran Mehta

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.
Legal decisions in critical 17

care units

Prof. Dr. Ram Shran Mehta

Medical documentation

Use of restraints

Declaring Brain death

Passive Euthanasia

Organ donation

Autopsy
Medical Documentation 18

Prof. Dr. Ram Shran Mehta

 Informed consent
 Advanced Directives
 Incident Reports
Informed Consent 19

Prof. Dr. Ram Shran Mehta

 In order to be considered legally
effective, consent to medical
treatment must meet three
tests:
(1) voluntary
(2) adequately informed or
knowing.
(3) given by an individual with
adequate mental capacity and
legal authority.
Advance directives 20

Prof. Dr. Ram Shran Mehta

 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.
Incident reports 21

Prof. Dr. Ram Shran Mehta

 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 22
documents

Prof. Dr. Ram Shran Mehta

 Consultations & referral slips
 Nurses record
 Treatment and investigation record
 TPR chart, BP monitoring chart, IO
chart/ Progress report
 Operative notes
 Discharge summary
 Death certificate
 23
Use of Restraints

Prof. Dr. Ram Shran Mehta

 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
24

Prof. Dr. Ram Shran Mehta

Nurses’ related factors influencing 25
the use of physical restraint in

Prof. Dr. Ram Shran Mehta

critical care units
 itcan 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 26

Prof. Dr. Ram Shran Mehta

 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 apnoea.
Passive euthanasia 27

Prof. Dr. Ram Shran Mehta

 Passive euthanasia is legal in India. On 7
March 2011 the Supreme Court of
India legalised passive euthanasia by
means of the withdrawal of life
support to patients in a permanent
vegetative state
Organ donation Decision 28

Prof. Dr. Ram Shran Mehta

 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.
 Organ Transplant Act, 2072 has also been
passed in Nepal.
 First brain death donor kidney transplant
was performed on May 2017.
Autopsy 29

Prof. Dr. Ram Shran Mehta

 Anautopsy 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.
 30

Prof. Dr. Ram Shran Mehta

Any Questions??