Critical Care Nursing semester LECTURE 6.pptx

CCN LECTURE 6.pptx

1. Sub: Critical Care Nursing Unit I : Conceptual Foundations in Critical Care Nursing Topic: Ethical and Legal Issues in Critical Care Nursing Lecture: 6 Mansoor ul Haq (Lecturer) MPH, BSN, PNS, LUMHS, Jamshoro

2. Introduction Ethics have always been an integral part of nursing. Nurses at all levels/areas of practices experience a range of ethical issues during the course of their day- to-day work. Critical care has come to be associated with high-tech, aggressive & often risk-filled medical care. The critical care nurse are often confronted with ethical & legal dilemmas related to various ethical principles & it has increased dramatically since the early 990s.

3. Ethical Principles Autonomy (freedom of making decisions for oneself) Beneficence (duty to do good to others & to maintain balance b/w benefits & harms. Nonmaleficence (no harm be done, either deliberately or unintentionally (not bad to do) Justice (deals with fairness, equity & equality) Veracity (duty to tell the truth & honesty, neither lying nor misleading others. Fidelity (faithfulness to a person)

4. Legal and Ethical Issues Informed Consent Consent problems arises because patients experiencing acute, life threatening illness that interfere with their ability to make decisions on treatment/ participation in clinical research. The informed consent is based on the principle of autonomy. Consent denotes voluntary agreement, permission or compliance. It implies to permission by the patient to perform an act on his body either for diagnosis or therapeutic procedure. The four elements of consent are; Voluntariness, capacity, knowledge, Decision making

5. Type of consent Implied Consent (consent which is not expressly granted by a person, but rather implicitly granted by a person’s actions and the facts & circumstances of particular situation e.g. if a medical practitioner collects a specimen to send to a pathology laboratory for testing, it would be reasonable to consider that the individual is giving implied consent to the passing of necessary information to that laboratory) Expressed consent: (verbal written)  

6. Points To Be Considered In Consent Consent must be given voluntarily If patient is not mentally capable (critical patients) informed consent should be obtained from surrogate or legal next of kin. It should be given by a person of sound mind & above the age of 18 years. Requires the disclosure of basic information considered necessary for decision making Patients providing consent should be free from pain & depression.

7. When consent invalid Consent obtained from a minor Consent given under fear, fraud or misrepresentation Consent obtained from the person who is not fit Consent obtained in language not understood by the person Consent obtained from person under sedation, intoxication or semiconscious Consent obtained without providing adequate information on the possible risks are invalid under law.

8. Medical Documentation The proper medical documentation is legal necessity. A good record should be correct, clear, comprehensive, chronological & contemporaneous. It is the fact that good records are indispensable for proper care & treatment of patients. Consent from patients before carrying out any procedure is mandatory legal, ethical & moral requirement. Similarly the document once prepared has also to be preserved for specified period of time (3 years from the date of commencement of treatment).

9. If any request is made for medical records either by patient/authorized attendant/legal authorities, the documents shall be issued within period of 72 hours & refusal to do so would be misconduct. The following medical documents are almost important as for as legalities are concerned: specialist consultations & referral slips, nurses record, treatment record, TPR chart, BP monitoring chart, IO chart, operative notes, anesthetists notes, progress report, final diagnosis, discharge summary & follow up notes etc. As for as medical legal issues are concerned e.g. death certificate, medico legal reports, medico legal investigation reports, all are of immense important & have to be very specific .

10. Use of Restraints Restraints are intervention that limits a person’s freedom to move. It can be physical or chemical. Researcher reported that the use of physical restraint can lead to: skin trauma, muscular atrophy, nosocomial infection, constipation, incontinence, limb injury, contractures, depression, anger, decline in functional & cognitive state & increasing agitation. Because restraints limit movement they also limit autonomy. Considering the physical, psychological & ethical aspects of physical restraint (risks & benefits), it is advocated that such is only used when all other methods of managing the problem have failed, employed with caution & as a last resort & use least restrictive method possible.  

11. Decisions Regarding Life Sustaining Treatmen t Usually there are two levels of treatment to consider is: Ordinary care (noninvasive & treatments like providing nutrition, hydration & antibiotic therapy) & Extraordinary care (complex, invasive & experimental treatments like CPR, advanced life support, dialysis & other therapies). However, the ethicists believe that any treatment can become extraordinary whenever the patient decides that the burdens outweigh the benefits.  

12. 1. Cardio Pulmonary Resuscitation Decisions Resuscitation efforts are used to reverse the clinical sign of death (loss of spontaneous respiration, loss of cardiac function & unconsciousness). Ethical questions arise on use of CPR & emergency cardiac care. In what situations should resuscitation efforts be used? How long should efforts continue? A generally accepted position is that resuscitation should cease if the physician determines the efforts to be futile or hopeless.

13. According to AHA 2000 health care providers may stop CPR when 30 minutes (adult/child) or 5 minutes (newborn) of advanced life support have been attempted without restoration of heart rate & breathing. The Do Not Resuscitate (DNR) order is still not documented legal practice in Pakistan. It is a verbal communication between the clinician & the patient’s relative or caregiver. The autonomy of the patient also remains a weak concept. The law is silent or ambiguous on most issues related to end-of-life care. The financial status of the patient appears to be the deciding factor. In most cases health-care expenses are entirely borne either by the patient or by the patient’s relative Withholding or stopping resuscitation efforts is ethically & legally appropriate if the patient/surrogate has previously made his preferences known through advanced directives.