Ms B and legal competence: examining the role of nurses in difficult ethico-legal decision-making

The case of Ms B throws up some interesting issues regarding the role of the nurse in assisting patients in making and implementing their decisions. The High Court transcript makes it clear who the voices with influence in legal matters were, and why the decisions they took were made. Absent from the myriad voices is that of the profession of nursing. Are nurses silenced by professional boundaries, the legal framework or lack of confidence? The concept of nursing advocacy is once again thrown into relief and critical questions need asking about the limits of professional nursing practice.

The Human Rights Act 1998: implications for anaesthesia and intensive care

The Human Rights Act 1998 was incorporated into UK statutory law on October 2, 2000. The 18 Articles of the Act are likely to have a significant impact on the practice of medicine in the UK, particularly in reference to consent, disclosure of medical information and patient access to healthcare. This article examines the implications of the new legislation for anaesthetic and intensive care practice.

Legal basis of decision-making in critical care

The issue of legal responsibility around decision-making in critical care units is one that can lead to confusion and uncertainty. This paper aims to examine the nature of decision-making in critical care and the legal basis for decision-making. The roles and responsibilities of doctors and nurses in critical care are explored. Both legal responsibility and legal accountability for decision-making in critical care are considered.

[Ethics and law in intensive therapy]

INTRODUCTION

Intensive therapy is one of the newest areas of medicine. The patient who was thought to be hopeless yesterday is given a chance to survive. As in other fields of medicine parallel with their development, several ethical and legal problems arise and wait for solutions.

AIMS

Two areas need urgent solutions especially at first ethical then at legal levels. These are the questions of life and death: where is the boundary of euthanasia and can the so called DNR ("Do Not Resuscitate") strategy be applied, which partial therapy withdrawal can be done compatibly with the basic ethical and legal requirement of protection of life. Important question as well, is that where lies the boundary of free self determination. How can be living wills be given when is it necessary to ask for the patient's consent, how much information is to be given to the patient.

METHODS

Based on increasing experiences form Europe and the USA, some of the important fundamental principles of therapy withdrawal of intensive care therapy is outlined. Besides the above described questions, a short description of the Hungarian conditions will be given.

RESULTS

Although the number of declarations given by professional corporations increase decisions of the jury help the medical practitioner in making his difficult decisions, but making the individual decision personal communication of the medical staff with the patient or his foster play an important role. Everything is the patient's right of free self determination based on the patient being properly informed. The ethical and even the legal attitude does not consider withdrawal of a widening circle of therapy to a form of euthanasia.

CONCLUSIONS

In the mirror of international experiences concordance is reached in many aspects of therapy withdrawal in intensive care. In the mean time national regulations are not yet available, this is the reason, why based on the international declarations, keeping an eye on the Hungarian practice these regulations should be worked out in the near future.

[Can the limits of intensive care management be defined?]

Medical treatment requires more than the application of techniques and devices. Knowing the limitations of (intensive) care and respecting patients' will and dignity is as important as technical skills. Limitations of therapy may arise from medical, ethical, legal, and economic reasons. Therapy may be limited through a Do-Not-Resuscitate (DNR) order, or by withholding or withdrawal of treatment. Total withdrawal of treatment ensues from proven brain death when organ donation has been denied or has been accomplished. But legislation as well as ethics and medical science fail to define unequivocal and precise criteria for limitation of treatment. Depending on the kind of disease, its prognosis and the patient's individual situation clinical scenarios can be identified when withholding or withdrawal of treatment may be thought of. The patient's expressed or anticipated wishes play a key role in decision-making on limitation of treatment. If the patient has no more decision making capacities physicians and patient's next of kin have to determine what would be in the patient's best interest. The patient and/or his family, all attending physicians and the nursing staff have to agree when limitation of care is taken into account. Hospital guidelines and written orders will help physicians and nursing staff to manage these difficult situations. Whether treatment has been limited or not, the patient and his family deserve all our medical and psychological skills--until the end.

[Ethical and legal problems in critical medicine]

The major ethical and legal problems in anesthesiology, intensive care, emergency and disaster medicine are discussed. Special attention is paid to violation of patient's rights, limits of intensive care and resuscitation, evaluation of iatrogenic complications and unfavorable outcomes from clinical physiological and legal viewpoints, and legal responsibility of anesthesiologists, intensive care specialists, and emergency physicians. Occupational hazards and protection of specialists in critical medicine are discussed.

Cultural differences in end-of-life care

The exact time of death for many intensive care unit patients is increasingly preceded by an end-of-life decision. Such decisions are fraught with ethical, religious, moral, cultural, and legal difficulties. Key questions surrounding this issue include the difference between withholding and withdrawing, when to withhold/withdraw, who should be involved in the decision-making process, what are the relevant legal precedents, etc. Cultural variations in attitude to such issues are perhaps expected between continents, but key differences also exist on a more local basis, for example, among the countries of Europe. Physicians need to be aware of the potential cultural differences in the attitudes not only of their colleagues, but also of their patients and families. Open discussion of these issues and some change in our attitude toward life and death are needed to enable such patients to have a pain-free, dignified death.

Critical palliative care: intensive care redefined

In the area of end-of-life bioethical issues, patients, families, and health care providers do not understand basic principles, often leading to anguish, guilt, and anger. Providers lack communication skills, concepts, and practical bedside information. Linking societal values of the sanctity of life and quality of life with medical goals of preservation of life and alleviation of suffering respectively provides an essential structure. Medical care focuses on cure when possible but when the patient is dying, the focus switches to caring for patients and their families. Clinicians need to learn how to balance the benefits and burdens of medications and treatments, control symptoms, and orchestrate withdrawal of treatment. Finally, all need to learn more about the dying process to benefit society, their own families, and themselves.

Brain death and organ donation

Critical care nurses are essential team members during the process of determining brain death and preparing for organ donation. Using their knowledge of the criteria for brain death, they care for the dying patient, support the grieving family, and participate in the consent process for organ donation. Nurses make a critical difference in saving the lives of others through the gift of life.

[Brain death and intensive care medicine. The cultural history of a medical concept]

The paper focuses on the cultural history of brain death in Germany in the second half of the 20th century. It analyzes scientific and public discourses on the relevance of brain death and the importance of medical innovations in intensive care medicine. The paper examines how the public reacted when heart transplantation led to an urgent need for a new definition of death. It will be shown how the concept of brain death was accepted by the public, introduced into clinical routine, and implemented through medical and legal policies. Finally, it will be analyzed why the public consensus on brain death was definitely questioned in the last ten years. An understanding of the use of the concept of brain death by scientists, lawyers, theologians, and the public during the last three decades may help to shed light on the social role of science in modern and late-modern societies.

ITU nurse found guilty of causing grievous bodily harm

Intensive care units are notoriously stressful environments. Nurses who work in intensive care have to endure sustained amounts of pressure and they have to be very careful of the effect that this pressure can have on them.

[Survey of practices of anesthetists and intensive care physicians in blood transfusion and blood monitoring]

In this paper, based on the results of a questionnaire, the author carried out a descriptive study about all the knowledges of the anaesthesists medicine on 1999 new law of blood transfusion. This work pointed out the progress that is still to be done, justifying a specialized formation in transfusion for all the people working in anaesthesiology.

Compliance with advance directives: nursing's view

The purpose for this article is to define the terms of the Advance Directive within the legal and medical community and then to explore the bioethical implications of the Advance Directive for the nurse. Over the last decade, a legal document has entered the arena of the health care facility: the Advance Directive. Today, not only is the critical care nurse responsible for technical handling of the ever-changing medical equipment, advances in medicine and nursing, and new pharmaceuticals, but this nurse is also responsible for being ever cognizant of a very important legal document called the Advance Directive.

The medical futility controversy: bioethical implications for the critical care nurse

Medical futility is a recent, complex bioethical issue. There is disagreement about how futility should be defined and who should be involved in futility decisions when an impasse exists between the patient/family and the physician. Bioethical discussions about Quinlan and Cruzan of the past have been replaced with the Wanglie, Baby K, and Linares cases--all of which involved critical care settings. Nurses often are involved in the debate and encounter ethical conflicts. Cost-containment, managed care, scarce resource allocation, and care due the elderly have fueled the debate. Key issues and their importance for critical care nurses will be reviewed.

"Slow" code: perspectives of a physician and critical care nurse

"Slow" codes are not conducted frequently, but even their limited use is controversial from an ethical point of view. Physicians and nurses may view the rationale for a "slow" code differently. A critical care nurse and a physician were interviewed regarding their experiences with and their views about "slow" codes.

[Treatment of patients incapable of giving their consent. Legal requirements in anesthesia and intensive care medicine]

A treatment procedure requires the consent of the patient, but this is legally effective only if he is capable of giving his consent and can be informed accordingly. Because of demographic development and the progress of medicine, the number of patients who are not able to give their consent is increasing. In practice, we make do with the presumed consent of the patient or, for procedures that can wait, with the consent of legitimate family members. An initiative action is suggested by physicians and hospitals that should reduce this gray zone and the forensic risks drastically.

Case 6: tracheostomy care. Intensive care sister who did not follow unit guidelines

Jean was a 35-year-old registered general nurse who worked on an intensive care unit (ICU) where she had been a ward sister for 5 years. On the day of this incident she was in charge of the early shift and had several junior staff under her authority. There were four patients on the unit. Jean had decided to care for a 70-year-old man with a chronic chest condition who had an acute chest infection. He had undergone a tracheotomy the previous week, was being mechanically ventilated and fed through a nasogastric tube. It was decided on the ward round that the patient's tracheostomy tube should be changed for the first time. Jean decided to carry out this procedure, assisted by one of the junior nurses.

Extubation in ICU: enhancing the nursing role

UKCC guidance gives a clear framework within which nurses can enhance their practice. Enhanced nurses can extubate patients with appropriate training and suitable protocols. Cost-effective, high-quality care can be provided by nurses working to the best of their professional knowledge and skill.

The use of restraints in critical care

A restraint is any physical or chemical measure used to limit activity or to control an individual's behaviour. Restraints may include locked rooms, locked chairs, mummy bags, jackets, vests, wristlets, anklets, belts, mitts, joint splints, or pharmacological agents. Clinical experience indicates that there is a high prevalence of restraint use in critical care areas. The use of restraints has become an important issue for health care professionals and is just beginning to be considered by critical care nurses. This article is intended to provide Canadian critical care nurses with a summary of the literature related to the use of restraints.

[Limits to the duty to treat in intensive care. 1. Explanation of the guidelines in the DGAI]

Every form of active euthanasia is a punishable offence under sections 216 of the Penal Code; nor is there any ethical justification for it from a medical point of view. The many strands of the movement in favour of making "death on demand" exempt from punishment in Germany as it is in The Netherlands cannot change this. In the area of passive euthanasia the limits of the intensive care team's duty to treat depends on various factors: The patient's declared or assumed wishes. It is not permissible to carry out procedures refused by the patient, even when these alone would make an extension of life possible. The indications for medical treatment. In the twilight zone between life and death, procedures with no prospect of success can no longer help the patient. In these circumstances they are pointless and are not medically indicated. According to Supreme Court rulings, the medical decision on whether to implement procedures designed to extend life or whether to withhold such procedures is based almost exclusively on the wishes or the assumed wishes of the patient, even though interpretation of the "assumed wishes" can be difficult and is quite often liable to subjective influences. The question of using the presence or absence of medical indications for treatment as an objective criterion, in contrast, has so far been disregarded in rulings. If no life-extending procedures are implemented the physician's duty to provide suitable basic care for the patient, in the sense of palliative care, remains. To make decisions easier, the authors discriminate between the essential "ordinary" remedies that must be provided to all patients and the "extraordinary" remedies of intensive care that are available for patients who can still benefit from them. There is some controversy over the correct assignment of artificial nutrition; according to German legislation it belongs in the category of extraordinary remedies. The palliative procedures that make up basic care include adequate pain relief, which can be a form of indirect euthanasia. The Supreme Court has ruled that it is the physician's duty to prescribe adequate pain relief even when it might have the unavoidable side effect of unintentionally accelerating the patient's death.

Is a murder charge an occupational hazard of intensive care nursing?

When nurses are accused of harming their patients there is an understandable wave of concern. When nurses kill their patients there is disbelief and horror. After all, killing patients is so far from the traditional image of the nurse as to cause distress and disorientation. When the nurse in question is a woman and when the charge amounts to serial killing, our most cherished assumptions about gender roles and professional responsibility are called into question. Yet in this decade nurses have been accused of killing patients, attempting to kill patients and causing grievous bodily harm to others. In the UK, of the nurses accused of attempting to murder their patients two came from the same specialism. Two of the three accusations centred on Intensive Care Units (ICU); the case of Amanda Jenkinson (Kenny 1996) and the case of Kath Atkinson, an ICU sister in Newcastle (Porter 1998a). In the most notorious case of nurse homicide in the UK this decade, that of paediatric nurse Beverly Allitt, the profession and society at large were shaken by accusations so serious as to defy belief.

Nurses' knowledge of advance directives

BACKGROUND

The Patient Self-Determination Act offers persons the opportunity to make their end-of-life choices known by the use of advance directives. Although nurses are designated advocates for patients and are available to communicate patients' concerns and wishes to other healthcare providers, few data on nurses' knowledge of advance directives have been reported.

OBJECTIVE

To describe nurses' knowledge of advanced directives.

SAMPLE

A volunteer sample of 339 RNs in a 600-bed acute care teaching hospital was surveyed. The sample represents 38% of the approximately 900 nurses employed at this hospital.

METHODS

Data obtained from a 44-item questionnaire that tested nurses' knowledge of advance directives were analyzed. In addition, the relationship between nurses' knowledge of advance directives and certain demographic factors was analyzed.

RESULTS

The mean score for knowledge of advance directives was 78% correct answers. Fifty-five percent of the respondents indicated that they did not have a good understanding of advance directives. Only 14% had completed these end-of-life documents for themselves, and 92% indicated that further education would increase their understanding of advance directives. An analysis of variance produced only one significant finding: the relationship between ethnicity and knowledge about advance directives.

CONCLUSIONS

Nurses must increase their knowledge of advance directives. Results of this survey should stimulate caregivers and hospital policy makers to take a long-range view of their responsibilities to patients regarding advance directives and their responsibilities for educating the persons who convey information about advance directives to patients.

Critical care research and pre-emptive informed consent: a practical approach used in Chris Hani Baragwanath ICU

OBJECTIVES

1) To establish a protocol within international and local ethical guidelines to obtain informed consent for critical care research, overcoming constraints previously described and 2) To evaluate eventual recruitment using this protocol.

DESIGN

Prospective descriptive study.

SETTING

Multidisciplinary ICU in a community-based university teaching hospital.

PATIENTS AND PARTICIPANTS

Following approval by the University Ethics Committee and Hospital Review Board, patients admitted between January and May 1996 were assessed on weekdays for potential enrollment into existing clinical trials. Discussion with potential candidates and/or next-of-kin occurred at the earliest opportunity and informed consent was obtained preemptively. Next-of-kin was notified if enrollment subsequently occurred. We evaluated the number of patients screened, the number of potential study candidates, the number for whom consent was obtained or refused and the number subsequently enrolled.

INTERVENTIONS

None

RESULTS

Of 249 patients screened, 149 (60%) did not meet the inclusion criteria. Of 100 potential study candidates (40% of all patients screened), we failed to make contact with the next-of-kin in 29 cases (12% of all patients screened). Thus 71 patients or next-of-kin were counselled (28% of all patients screened). In all, 30 patients (12% of all patients screened) were subsequently enrolled into a study.

CONCLUSIONS

A policy of pre-emptive informed consent enabled us to overcome some of the problems previously experienced in our unit with regards to patient enrollment in critical care research. Although overall recruitment remained low, predictions for future enrollment can be made from this study.

[Ethical aspects and problems in intensive care medicine]

In the Intensive Care Unit important decisions in critically ill and often incompetent patients have to be made within a short period of time and without all the necessary information. Two main questions arise: 1. How can the autonomy of the patients be respected under these circumstances? 2. Which diagnostic and therapeutic activities are adequate and reasonable in each individual patient? An optimal communication between the people involved helps to find the best answers.

Assisted suicide, recent judicial decisions, and implications for critical care nurses

The passage of the Oregon Death With Dignity Act on November 8, 1994, heralded a wake-up call for healthcare professionals. Oregon, the first state to systematically "ration care" was thought to be a fertile ground for testing new and, some say, radical concepts in healthcare and government. Although the act was not implemented because it was tied up in legal action until February 1997, the fact that more than 50% of the voters in Oregon voted for it mandates that healthcare providers listen to their patients. Patients want more control of their pain, the way they die, and the resources spent on their care in the final days of their lives. Thoughts of future suffering engender great fear on the part of healthcare consumers. Concern exists that physician-assisted suicide in the ICU will affect not only physicians but also nurses, pharmacists, respiratory therapists, and other clinicians as terminally ill patients make requests for assisted suicide while in the acute and critical care setting of the hospital. Critical care nurses must examine their value systems, review the Code for Nurses, and make their own decisions about participation in deliberately ending lives of patients. With the impending Supreme Court decision due in July 1997, the court may leave these issues to the individual states, opening the door for assisted suicide to occur throughout the United States. Therefore, the possibility will remain that critical care nurses may be put in positions in which physicians are providing assistance to patients who wish to commit suicide and are requesting nurses' assistance to do so.

[Studies carried out in the province of Nuoro on treatment modalities for oncologic pain during the terminal phase]

The purpose of this first level research is to analyze the organization of the treatment of oncological pain in one Italian province. For the data collection a questionnaire was submitted in the Intensive Care Unit to the responsibles and to the staff in the public hospital structures of the six USL of the Nuoro's province. Results prove that the motivation of the staff and their problem sensitivity, are inadequate to guarantee an effective answer to the patient's need. The main aspects are: legal aspect, concerning the district level interventions ache care formation aspect for registered nurses the necessity to adopt quality evaluation methods.

[Medical liability in the treatment of intensive care unit patients]

Critical care medicine was practiced informally during several years, specially during war periods. Nowadays it is, however, a fundamental part of health systems in which patients attain care facilities of increasing complexity in a cost effective manner, according to their needs. The importance of this discipline in Chile, during its 30 years of development, has progressively increased and at the present time, intensive care units represent up to 30% of the total number of beds in some hospitals. Even though these units require great budgets and many resources, their place and the role of physicians who work in them has not been recognized adequately by the national medical community. The present document presents the official position of the Chilean Society of Intensive Medicine on the general objectives of this discipline. It indicates the scope of action of the specialty and the role of intensive care physicians, their relationship with other specialties, their duties and responsibilities with their patients.