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.