Separating medical and ethical: helping families determine the best interests of loved ones

Deciding together? Best interests and shared decision-making in paediatric intensive care

In the western healthcare, shared decision making has become the orthodox approach to making healthcare choices as a way of promoting patient autonomy. Despite the fact that the autonomy paradigm is poorly suited to paediatric decision making, such an approach is enshrined in English common law. When reaching moral decisions, for instance when it is unclear whether treatment or non-treatment will serve a child's best interests, shared decision making is particularly questionable because agreement does not ensure moral validity. With reference to current common law and focusing on intensive care practice, this paper investigates what claims shared decision making may have to legitimacy in a paediatric intensive care setting. Drawing on key texts, I suggest these identify advantages to parents and clinicians but not to the child who is the subject of the decision. Without evidence that shared decision making increases the quality of the decision that is being made, it appears that a focus on the shared nature of a decision does not cohere with the principle that the best interests of the child should remain paramount. In the face of significant pressures toward the displacement of the child's interests in a shared decision, advantages of a shared decision to decisional quality require elucidation. Although a number of arguments of this nature may have potential, should no such advantages be demonstrable we have cause to revise our commitment to either shared decision making or the paramountcy of the child in these circumstances.

What to do when the family cannot agree to withdraw life support

This article describes a family who could not agree to withdraw life support from a ventilator-dependent woman who was unresponsive and whose death was inevitable. Evidence-based recommendations are given and resources identified to assist critical care nurses to facilitate discussions among family members who disagree about end-of-life care and to help nurses discuss end-of-life orders, address cultural issues, manage family conflict, assist families to make decisions, and act with moral courage and ethical humility when supporting families and each other during withdrawal of life support.

Identifying ethical issues from the perspective of the registered nurse

A review of the formal ethics consultations performed at a rural academic medical center during 2006 revealed that only 5 of 72 consultations were initiated by nurses. A descriptive exploratory convenience study used a 3-item survey to collect information from registered nurses who provide direct patient care at the rural academic medical center. The purpose of this study was to (1) identify and describe the ethical issues perceived by registered nurses employed at a rural academic medical center and (2) analyze the variables influencing the registered nurses' ethical decision making and the process used by these registered nurses when resolving ethical issues.The 17 registered nurses who completed the survey identified a total of 21 ethical issues that they had experienced during the last year. The ethical issues that nurses recalled were significantly more likely to be relationship issues, whereas issues documented within the ethics consultation service were significantly more likely to involve limiting treatment. Communication was a major variable influencing nurse's ethical decision making. Nurses felt the ethical issue resolved satisfactorily when the patient's needs were met, communication occurred with the patient and/or family, the entire healthcare team was involved and in agreement, and there was sufficient time available to make a decision. The nurses did not feel that the ethical situation was resolved satisfactorily when not handled from the patient's perspective; the patient suffered; there was a lack of teamwork, agreement, and/or support; and the process took too long. The nurses' recommendations for resources needed to assist with the resolution of ethical issues included accessible ethics mechanisms, education, improved interprofessional relationships and collaboration, and unbiased support for patient and family decision making. Implications for nurse managers are discussed and future research questions are identified.