LEGAL AND ETHICAL ISSUES IN CRITICAL CARE

Ethics is an integral part of foundation of nursing.Ethics refers to systematic study of those standards and values.Ethics is a inquiry that helps us to answer questions As new ethical issues in critical care continue to emerge,practioners in critical care must develop skills in moral reasoning. An ethical dilemma occurs when two or more morally acceptable courses of action are present and to choose one prevents selecting other.competence in moral decision making evolves throughout professional career.however,there are general moral principles and guidelines that direct ethical reasoning and provide a standard to which professional nurses are held. FOUNDATION FOR ETHICAL DECISION MAKING Professional Codes and Standards:The purpose of professional code is to identify the moral requirements of profession and the relationships in which they engage.the code for nurses developed by American nurses association(ANA)articulates essential values, principles and obligations that guide nursing actions.it identifies common moral themes that arise in nursing practice and provides a framework for moral inquiry. In addition to code of ethics, nurses function in accordance with particular standards of practice.standards of nursing practice are delineated by professional organizations and statutory bodies that govern practice of nursing in various jurisdictions. External bodies such as stata boards of impose certain regulations for licencure, regulate practice of nursing and evaluate and monitor actions of professional nurses. Many organizations also delineate standards of practice for registered nurses practiced in defined area of speciality. Nurses are expected to function within professions code of ehics and are held morally and legally accountable for unethical practice. The American Nurses Associationss(ANA)code of Ethics for Nurses:1. The nurse,in all professional relationships,practices with compassion and respect for inherent dignity,worth and uniqueness of every individual,unrestricted by considerations of social or economic status,personal attributes or nature of health problems. 2. The nurses primary commitment is to the patient,whether an individual,family group or community. 3. The nurse promotes,advocates for and strives to protect the health,safety,and rights of patient. 4.The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care. 5. The nurse owes the same duties to self as to others,including the responsibility to preserve integrity and safety to maintain competence and to continue personal and professional growth. 6. The nurse participates in establishing,maintaining and improving health care environments and conditions of employment conducive to provision of quality health care and consistent with values of profession through individual and collective action. 7. The nurse participates in advancement of the profession through contributions to practice,education,administration and knowledge development.

8. The nurse collaborates with other health care professionals and public in promoting community, national and international efforts to meet health needs. 9. The profession of nursing as represented by associations and their members is responsible for articulating nursing values for maintaining integrity of profession and its practice and for shaping social policy. Position Statements and Guidelines:The purpose of position statements is to apply the values,principles and rules described in code for nurses to particular contemporary ethical issues.e.g the code of nurses and ANA position statements on assisted suicide and active euthanasia clarify nurses role when such requests are made. Institutional policies:Because critical care nurses practice within organizations,institutional policies and procedures affect and direct their practice. These policies usually reflect ethical expectations congruent with professional code of ethics. Institution often provide internal resources to help clinicians resolve difficult ethical issues. Institutional ethics committees provide consultation on ethical situations and institutional policies outlining the procedures of case review should be available to all employees. Legal Standards:- Public policies and state and federal laws directed at health care influence the practice of health care professionals.state and federal laws often complement public policies and reinforce the position set forth. Critical care nurses must understand legislation that directly influencing advance directives. Principles of Bio-Ethics:One of dominant and most influential perspectives in bio-medical ethics is that of principle ethics.These basic principles and derivate imperative rules are considered prima facie or binding. The primary principles used are Nonmalficence, Beneficence,utility,justice and respect for persons or autonomy.the derivative principles or rules include privacy, Confidentiality,Veracity and Fidelity. Nonmaleficence:-The principle of nonmaleficence imposes the duty to do no harm.this suggests that nurse should not knowingly inflict harm and is responsible if negligent actions result in detrimental consequences.In general,a critical care nurse preserves the principle of nonmaleficence by maintaining competence and practicing within accepted standards of care. Beneficence:-This principle affirms that an obligation to prevent harm,remove harm,and promote good by actively helping others to advance and realize their interests.the nurse actively prevent and remove harm,provides safe and competent care and by promoting the well being of others. When the patients safety or well being is threatened by action of others,the nurse is obliged to remove to remove and prevent harm. knowledge of unsafe, illegal or unethical practice by health care provider obligates nurse both morally and legally to intervene. Nurses are expected to practice according to established standards of practice, to continue professional learning to improve clinical practice and to refrain from providing care measures in which they are not proficient.

Utility:- This concept advocates for positive balance of benefits over burdens.Benefits contribute to patients well being by improving patients health.Burdens on other hand,produce no measurable improvement in health or quality of life and may increase patient suffering or debilitation. Respect for Autonomy:This principle affirms the freedom and right of an individual to make decisions and choose actions based on that individual personal values and beliefs.to repect a persons autonomy is to recognize that patients may hold certain views and take particular actions that are incongruent with values of health care providers.the critical nurse advocates for patient by promoting as much as possible the factors that constrain patients freedom to make autonomous choices. Justice:This principle requires that similar cases be treated in similar ways and that all persons are to be treated according to its needs.Patients are to be treated equally regardless of disease state,socioecomic status,gender,age,religious ,beliefs or morale convictions. Critical care nurses allocate nursing resources to patients,other members of health care team,and other areas within the institution. Privacy and Confidentiality: Privacy refers to the right of an individual to be free from unjustified access by others. Confidentiality is described in terms of protection of information.when the patient shares information with the nurse or member of health care team,the information should be treated as confidential and discussed only with those directly involved in patients care. Verality:- The rule of veracity simply means that one should be tell truth and not lie or deceive others.patients expect that information about their condition will be relayed in an open,honest and sensitive manner.without truthful communication,patients are unable to assess the options available and make fully informed decisions. Fidelity:-It is the obligation to be faithful to commitments and promises and uphold the promises and uphold implicit and eplicit commitments to patients,colleagous, and employers.the nurse maintains a faithful moral relationship with patient,communicating honestly and meeting obligations to oneself,the profession of nursing,other health care professionals and employer. Legal Issues in Critical Care:The registered nurse adheres to five principles for protection of patient and practioner. Five legal responsibilities:y Performs only those functions for which he or she has been prepared by education and experience. y Performs those functions competently y Delegates responsibility only to personnel whose competence has been evaluated and found acceptable. y Takes appropriate measures as indicated by observation of patient. y Is familiar with policies of employing agency.

Advance directives Advance directives are statements made by an individual with decision making capacity that describe the care or treatment he or she wishes to receive when no longer competent. Most states recognize two forms of advance directives,the treatment directive or living will.and the proxy directive. The treatment directive enables the individual to specify in advance his or her treatment choices and which interventions are desired. Usually treatment directives focus on cardiopulmonary resuscitation(CPR),mechanical ventilation,nutrition and hydration and other life sustaining technologies. Brain Death:- Brain death is the irreversible end of all brain activity (including involuntary activity necessary to sustain life) due to total necrosis of the cerebral neurons following loss of brain oxygenation. It should not be confused with a persistent vegetative state. Brain death, either of the whole brain or the brain stem, is used as a legal indicator of death in many jurisdictions. Clinical Criteria for Brain Death in Adults and Children
y y y y y y y y y

Coma Absence of motor responses Absence of pupillary responses to light and pupils at midposition with respect to dilatation (46 mm) Absence of corneal reflexes Absence of caloric responses Absence of gag reflex Absence of coughing in response to tracheal suctioning Absence of sucking and rooting reflexes Absence of respiratory drive at a PaCO2 that is 60 mm Hg or 20 mm Hg above normal base-line values

It is important for nurse to know legal definition of death in any state where he or she is practicing.a patient who is brain dead,and there is no legal duty to continue to treat him or her.it is not necessary to obtain court approval to discontinue life support on a patient who us brain dead.Furthermore,although it can be desirable to obtain family permission to discontinue treatment of brain dead patient,there is no legal requirements.however,before terminating life support,physicians and nurses should be sure that organs are not intended for transplant purposes. Organ donation:- Organ donation is the donation of biological tissue or an organ of the human body, from a living or dead person to a living recipient in need of a transplantation. Transplantable organs and tissues are removed in a surgical procedure following a determination,

based on the donor's medical and social history, of which are suitable for transplantation. Such procedures are termed allotransplantations, to distinguish them from xenotransplantation, the transfer of animal organs into human bodies. The necessary steps to get on a national waiting list: 1. Obtain a referral from a physician. 2. Contact a transplant hospital Learn as much as possible and choose one based on individual needs, including insurance, location, finances, and support group availability. 3. Schedule an appointment for evaluation at the transplant hospital to determine if you are an appropriate candidate for a transplant. 4. During the evaluation, ask questions to learn as much as possible about the hospital and its transplant team. 5. Once the evaluation is completed, the hospital's transplant team will determine when it is appropriate to be added to the national waiting list. The whole organ donation process can be, for convenience, divided into four distinct phases. The process of: 1.Identification 2 Certification 3. Screening 4.Maintenance of donor The statues establish the legality of organ donation by individuals and their families and set procedures for making and accepting the gift of an organ.Every state also has some provision to enable people to consent to organ donation using designated place on drivers licence.more recently,many states have enacted required request laws.These laws attempt to increase supply of organs for transplant by requiring hospital personnel to ask patientss families about an organ gift at time of patients death. Do not Resuscitate(DNR)Orders:- In medicine, a "do not resuscitate" or "DNR" is a legal order written either in the hospital or on a legal form to respect the wishes of a patient to not undergo CPR or advanced cardiac life support if their heart were to stop or they were to stop breathing. This request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect their wishes. CPR success rates for those receiving in-hospital care are quite variable and are affected by patient environment and resuscitative efforts. However,CPR is not appropriate for all patients who experience a cardiac arrest because it is highly invasive and may constitute a positive violation of an individuals right to dignity. Furthermore,CPR may not be indicated when illness is terminal and irreversible and when patient can gain no benefit.

Most hospitals and medical socities and some states have published DNR policies. Whether to resuscitate any patient is decision that is made by attending physician,the patient,and the family,although critical care nurses and other nurses often have substantial input into decision.however,the consent of competent patient should be required when DNR order is written.if patient is incompetent,the physician and family members make the decision.the situation can be more complex,and the physician and the family or patient can disagree. Once DNR decision has been made,the order should be written,signed, and dated by responsible physician.it should be reviewed periodically;hospital pocicies may require review every 24 to 72 hours.the more informal methods of designating patients with whom CPR is not be underetaken can lead to errors if an arrest occurs.e.g the wrong patient can be allowed to die. Euthanasia:- Euthanasia (from the Greek meaning "good death": refers to the practice of intentionally ending a life to relieve pain and suffering. There are different euthanasia laws in each country. Classification of Euthanasia Euthanasia may be classified according to whether a person gives informed consent into three types: voluntary, non-voluntary and involuntary. Voluntary euthanasia:Euthanasia conducted with the consent of the patient is termed voluntary euthanasia. Non-voluntary euthanasia:Euthanasia conducted where the consent of the patient is unavailable is termed non-voluntary euthanasia. Examples include child euthanasia. Involuntary euthanasia:Euthanasia conducted against the will of the patient is termed involuntary euthanasia. Living will:A living well is written directive from a competent patient to family and health care team members concerning patients wishes in event the patient is unable to express these wishes.In most cases,a living will becomes effective only if patient is terminally ill or permanently comatose.consequently.when patient is critically ill or temporarily unable to make health care decisions,living will is not operative. The living will is the oldest form of advance directive A living will usually provides specific directives about the course of treatment that is to be followed by health care providers and caregivers. In some cases a living will may forbid the use of various kinds of burdensome medical treatment. It may also be used to express wishes about the use or foregoing of food and water, if supplied via tubes or other medical devices. The living

will is used only if the individual has become unable to give informed consent or refusal due to incapacity. A living will can be very specific or very general. An example of a statement sometimes found in a living will is: If I suffer an incurable, irreversible illness, disease, or condition and my attending physician determines that my condition is terminal, I direct that lifesustaining measures that would serve only to prolong my dying be withheld or discontinued. More specific living wills may include information regarding an individual's desire for such services such as analgesia (pain relief), antibiotics, hydration, feeding, and the use of ventilators or cardiopulmonary resuscitation.

Bibliography: Patricia gonce morton, Dorrie gonce fontanie; Critical care nursing;a holistic approach ;eighth edition;page no-77-89  Marriane chulay, Suzanne M.burns; AACN essentials of critical care nursing; international edition;page no.199-210  http://www.donateyourorgan.com/organdonation/organdonationprocess.aspx http://www.medicalcriteria.com/site/  http://en.wikipedia.org/wiki/Advance_health_care_directive  www.google.com