This document discusses the ethical and legal responsibilities of critical care nurses. It begins by distinguishing between ethical and legal standards, with ethical standards based on principles of right and wrong and legal standards based on written law. It then outlines some common ethical dilemmas nurses may face including end-of-life decisions, patient care issues, and human rights issues. It also discusses legal decisions around topics like medical documentation, use of restraints, and declaring brain death. The document provides recommendations for resolving ethical dilemmas and outlines practical principles for ethical decision making including effective communication and determining patient desires. It emphasizes the importance of shared decision making at end-of-life.

1. CRITICAL CARE NURSING:
Ethical & Legal Responsibilities
1Prof. Dr. Ram Sharan Mehta, MSND, CON, BPKIHS

2.  In law a man is guilty when he
violates the rights of others. In
ethics he is guilty if he only
thinks of doing so.
-Immanuel Kant
Prof. Dr. R S Mehta, BPKIHS 2

3. Ethical & Legal
Decisions in
Critical Care
Units

4. Learning Objectives
 Distinguish between ethical and legal
standards.
 Review ethical principles.
 Discuss common ethical dilemmas and
decision.
 Discuss the common legal decision in
critical care units.

5. Ethical
Standards
• Based on
human
principle of
right & wrong
Legal Standards
• Based on
written law

6. Ethical Decision
Making
 emerged in the recent years as a
major component of health care
for the critically ill patients.
 refers to the process of
evaluating and choosing among
alternatives in a manner
consistent with ethical principles.

7. Ethical principles
• Patient’s right to self
determination.Autonomy
• do no harm.Non-maleficent
• promoting goodBeneficence
• the obligation to tell the truth.Veracity
• faithfulness to agreements &
responsibilitiesFidelity
• the fair allocation of medical
resources.Justice

8. Ethical Dilemmas Experienced by Nurses
Working in Critical Care Units:
 Identified “end-of-life decisions,
Patient care issues and human
rights issues” as the emerging ethical
issues.
 In resolving the dilemmas most of the
participants indicated that they would
report the issues to the physician.

9. Ethical Decisions
End-of-life Issues
• Palliative Care
• CPR decisions
• Euthanasia
• Withholding & withdrawing treatment
• Futile care

10. Practical Principles for
Ethical decision making
 Identify source of authority for
decision making.
 Achieve effective communication
with patient and families

11. Practical Principles for
Ethical decision making
 Carry out early determination and
ongoing review of patient’s desire.
 Clearly recognize patient’s rights.
 Carry out hospital policies.
 Protect the nurse’s own standards of
care.

12. Recommendations for end-of-life care in
the intensive care unit: A consensus
statement by the American College of
Critical Care Medicine
 Concluded that End-of-life care is
emerging as a comprehensive area of
expertise in the ICU & highlighted the
importance of shared decision
making and the importance of caring
for patients’ families

13. Palliative care
 caring for a patient to relieve pain and
make the dying process as peaceful as it
can be.
 Depending on patients' wishes, they are
given food and hydration.

14. CPR Decisions
 Ethical questions on CPR: in what
situations, for how long?
 Do not resuscitate(DNR): orders are
commonly implemented in the
critical care setting as a prelude to
end-of-life care.

15. Euthanasia
 Euthanasia, a Greek word meaning
“good death,” is popularly known as
“mercy killing.”
Active euthanasia
Passive euthanasia

16. Withholding or withdrawal of
life support
 Withholding: never
initiating a treatment
 Withdrawing: to stop a
treatment once started
 Best made after careful
discussion (health care
professional, patient and
family)

17. Futile care
 Futile medical care
is the continued
provision of
medical care or
treatment to a
patient when there
is no reasonable
hope of a cure or
benefit.

18. Perceptions of “futile care”
among caregivers in intensive
care units
 Respondents felt that futile care was
provided because of family demands, a
lack of timely or skilled communication,
or a lack of consensus among the
treating team.

19. Legal decisions in critical
care units
Medical documentation
Use of restraints
Declaring Brain death
Passive Euthanasia
Organ donation
Autopsy

20. Medical Documentation
 Informed consent
 Advanced Directives
 Incident Reports

21. Informed Consent
 In order to be considered
legally effective, consent to
medical treatment must meet
three tests:
(1)voluntary
(2)adequately informed or
knowing.
(3)given by an individual with
adequate mental capacity
and legal authority.

22. Advance directives
 is a document by which a person makes
provision for health care decisions in the
event that, in the future, he/she
becomes unable to make those
decisions.
 These directives may also designate a
specific surrogate decision maker who
then has ethical and possibly legal
standing to make medical decisions for
the patient.

23. Incident reports
 Document the occurrence of anything out
of the ordinary that results in, or has the
potential result in, harm to a patient,
employee or visitor.
 The nurse responsible for a potentially or
actually harmful incident or who witnesses
an injury is the one who fills out the
incident form.

24. Other Important legal
documents
 Consultations & referral slips
 Nurses record
 Treatment and investigation record
 TPR chart, BP monitoring chart, IO
chart/ Progress report
 Operative notes
 Discharge summary
 Death certificate

25. Use of Restraints
 Intervention that limits a
person’s freedom to
move
 Physical or chemical.
 Use only when all other
methods have failed
 as a last resort
 use least restrictive
method possible

27. Nurses’ related factors influencing
the use of physical restraint in
critical care units
 it can be concluded that those older
nurses and those with higher
qualification and years of experience
have better performance than others.
 Nurses’ knowledge and performance are
in need for improvement

28. Declaring Brain death
 Require a physician not involved in the
patient treatment to document brain
death and another physician to confirm
the findings
 3 essential findings in brain death are
coma, absence of brainstem reflexes,
and apnoea.

29. Passive euthanasia
 Passive euthanasia is legal in India. On 7
March 2011 the Supreme Court of
India legalised passive euthanasia by
means of the withdrawal of life support to
patients in a permanent vegetative state
 In Nepal?

30. Organ donation Decision
 The donation can be made by a
provision in a will or by signing a card-
like form.
 Nurses may serve as witnesses for
people consenting to donate organs.
 Organ Transplant Act, 2072 has also
been passed in Nepal.
 First brain death donor kidney transplant
was performed on May 2017.

31. Autopsy
 An autopsy or postmortem examination is
an examination of the body after death.
 The law describes under what
circumstances an autopsy must be
performed, for example, all Medico-Legal
Cases should undergo autopsy.

32. Some Common Concepts:
Prof. Dr. R S Mehta, BPKIHS 32

33. Patient’s bill of rights
1. Right to considerate & respectful care.
2. Right to information
3. Right to make decisions
4. Right to have advance directive
5. Right to privacy
6. Right to confidentiality
7. Right to review the records
8. Right to proper treatment and referral
9. Right to ask & be informed of the existing business relationship
among hospital , educational institutions, other health care
providers or payers
10. Right to consent to participate in research
11. Right to reasonable continuity of care
12. Right to be informed of hospital policies.
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34. Which cases are medico legal?
 All cases of injuries.
 All cases of burn.
 Alleged cases of assault.
 All cases of suspected or evident of poisoning or intoxication.
 Case referred from court
 Cases of suspected or evident criminal abortion
 Cases of unconscious/comatose where its cause is not
natural or not clear
 Cases brought dead/dead on arrival/sudden unexpected
death etc
 Cases of suspected self inflicted injuries or attempted suicide
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35. Important legal documents
 Specialist consultations & referral slips
 Nurses record
 Treatment record
 TPR chart, BP monitoring chart, IO chart/ Progress
report
 Operative notes, Anesthetists notes
 Final diagnosis
 Discharge summary & follow up notes/ death
certificate
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36. “4 A’s” and “4 R’s”
A resource developed by the American Association of
Critical-Care Nurses (AACN). The 4 A’s are sequential
steps in raising one’s awareness and committing to
action.
1. Ask – Reflect to become aware of your feelings of moral
distress. Are you and/or team members experiencing moral
distress?
2. Affirm – Validate your feelings with others and make a
commitment to address moral distress.
3. Assess – Assess the degree of your distress and your readiness
to act.
4. Act – Make a personal and professional action plan. Carry it out
and act to sustain the change.
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37.  If you are uncertain about taking
action, the 4 R’s can help you to
clarify:
1. Relevance – In what ways and to who is the issue
important?
2. Risks – What are the risks of taking action and of
NOT taking action?
3. Rewards – What benefits can be obtained by
acting and various courses of action?
4. Roadblocks – What are the barriers to taking
action or a particular course of action?
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38. Legal safeguards for nurses
 Informed consent
 Contract
 Collective bargaining
 Competence practice
 Licensure
 Patient education
 Executing physician’s order
 Documentation
 Professional liability insurance
 Good samaritan law
 Adequate staffing
 Patient’s bill of rights
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39. Nursing council act 2052
 A person who carries on the nursing
profession in contravention of Section 20
(Prohibition on carrying on nursing
profession: No person other than a
registered nursing professional shall be
entitled to carry on the nursing
profession, directly or indirectly)shall be
punished with a fine not exceeding Three
Thousand Rupees or with imprisonment for
a term not exceeding Six months or with
both.
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40. Consumer protection act 2054
 A person who commits or cause to commit
any Act in violation of Section 10 (To
mislead consumers by making false or
misleading claim that the consumer goods
or service, to engage in unfair trade
practices in such a manner as to make false
or misleading publicity or advertisements)
shall be punished with imprisonment for a
term not exceeding five years, or with a fine
not exceeding One Hundred Thousand
Rupees or with both.
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41. To produce, sell or supply any of the consumer goods
or services which may cause harm to the health of the
consumers
1 )If there is a threat to life, for a term not exceeding
fourteen years, or with a fine not exceeding Rs 500,000,
or with both.
(2) In case the strength of any organ of the body is likely to
be reduced or lost, with imprisonment for a term not
exceeding ten years, or with a fine not exceeding Rs
500,000, or with both.
(3) In other circumstances, with imprisonment for a term
not exceeding five years, or with a fine not exceeding Rs
300,000, or with both.
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42. “For the implementation of high quality of nursing
practice in the world of latest medical and
technological advances, good knowledge of legal
right is necessary.”