A history of ethics and law in the intensive care unit

Physicians' Conceptions of the Dying Patient: Scoping Review and Qualitative Content Analysis of the United Kingdom Medical Literature

Most people in high income countries experience dying while receiving healthcare, yet dying has no clear beginning, and contexts influence how dying is conceptualised. This study investigates how UK physicians conceptualise the dying patient. We employed Scoping Study Methodology to obtain medical literature from 2006-2021, and Qualitative Content Analysis to analyse stated and implied meanings of language used, informed by social-materialism. Our findings indicate physicians do not conceive a dichotomous distinction between dying and not dying, but construct conceptions of the dying patient in subjective ways linked to their practice. We argue that the focus of future research should be on exploring practice-based challenges in the workplace to understanding patient dying. Furthermore, pre-Covid-19 literature related dying to chronic illness, but analysis of literature published since the pandemic generated conceptions of dying from acute illness. Researchers should note the ongoing effects of Covid-19 on societal and medical awareness of dying.

When law and ethics come apart: Constraints versus guidance

The generally agreed upon principle that legality and ethics can come apart is frequently overlooked in our professional ethics education and decision-making procedures. The crux of the issue is that we teach in our philosophy classes that the law can sometimes be unethical, but then clearly state in nursing codes of ethics that students should always follow the law. The law could no doubt give us some reason to choose action A over action B, but in professional contexts we frequently treat the law as a side-constraint that limits the logical space of choices to exclude even consideration of action B. If B is the mandatory action, this in effect forces professionals to do something unethical by preventing them from ever seeing the ethical action as an option. This is a problem. Ultimately we concede that there might be an irresolvable tension in competing normative interests in ethics and the law, though we suggest that a more nuanced approach to ethical code formation could help alleviate the issue somewhat.

Approaches to the initiation of life-sustaining technology in children: A scoping review of changes over time

Little is understood about the dynamic circumstances within which the initiation of technology dependence takes place in children. The aim of this scoping review was to identify the influences on the initiation of technology dependence and the issues that require further exploration and consideration. Scientific literature that directly or indirectly discussed the initiation of technology dependence in children was identified. A three-stage screening process of title and abstract scrutiny, full-text scanning and in-depth full-text reading resulted in 63 relevant articles from 1133 initially reviewed. These were then subjected to descriptive and thematic analysis. Articles ranged from the 1970s to the present, reflecting the evolution of ethical debates around the approaches to clinical practice and changes in cultural and societal attitudes. Three themes emerged: how technology alters the meaning of futile care, dissonance in the perspectives of decision makers and increasing support for joint decision-making. Only articles in English and predominantly from the clinician's rather than the patient's perspective were included. Societal and cultural factors as well as the structural, financial and cultural environment influence the initiation of technology dependence in children. However, to what extent these overt and implicit influences guide decision-makers in this field remains largely unknown.

Advance Care Planning for Intensive Care Patients During the Perioperative Period: A Qualitative Study

INTRODUCTION

Patients in intensive care units (ICUs) may transition into an end-of-life phase during treatment. Advance care planning (ACP) for this population has not been studied comprehensively, and support for its implementation is insufficient.

OBJECTIVE

This study aims to clarify the ACP support needs among critical perioperative patients.

METHODS

In this qualitative descriptive study, semistructured interviews were conducted with patients previously admitted to the ICU. The survey was conducted from September to November 2019. Participants comprised 13 individuals, who were admitted to the ICU for a period of 3 months to 2 years after surgery.

RESULTS

The average age of the participants was 63.8 years. The average mechanical ventilation duration following surgery was 24.5 h. The interviews focused on the ACP needs from the preoperative period to discharge. About 90% of the patients thought about the possibility of death before surgery and considered giving advance orders (e.g., "I don't want life-sustaining treatment"). The participants discussed inheritance, work-related matters, and household issues with their families but rarely spoke about treatment and care. Although they examined the content of the advance directives, the medical staff was not informed about them. Patients revealed that they wanted to understand the distinction between life-prolonging and life-saving treatments and discuss it with the medical staff, apart from being educated on ACP. Many patients previously admitted to the ICU are unclear about the difference between life-prolonging and life-saving treatments; this is also true for medical staff.

CONCLUSION

Patients who had been admitted to the ICU after high-risk surgery thought they needed help with ACP before surgery. Therefore, patients have the right to know about treatment risks; however, medical staff believes that this is difficult to communicate. Thus, medical staff should consider ways to communicate clearly with patients, including discussing the risks associated with surgery.

Survey of End-of-Life Care in Intensive Care Units in Ain Shams University Hospitals, Cairo, Egypt

Studies on end-of-life care reveal different practices regarding withholding and/or withdrawing life-sustaining treatments between countries and regions. Available data about physicians' practices regarding end-of-life care in ICUs in Egypt is scarce. This study aimed to investigate physicians' attitudes toward end-of-life care and the reported practice in adult ICUs in Ain Shams University Hospitals, Cairo, Egypt. 100 physicians currently working in several ICU settings in Ain Shams University Hospitals were included. A self-administered questionnaire was used for collection of data. Most of the participants agreed to implementation of "do not resuscitate" (DNR) orders and applying pre-written DNR orders (61% and 65% consecutively), while only 13% almost always/often order DNR for terminally-ill patients. 52% of the participants agreed to usefulness of limiting life-sustaining therapy in some cases, but they expressed fear of legal consequences. 47% found withholding life-sustaining treatment is more ethical than its withdrawal. 16% almost always/often withheld further active treatment but continued current ones while only 6% almost always/often withdrew active therapy for terminally-ill patients. The absence of legislation and guidelines for end-of-life care in ICUs at Ain Shams University Hospitals was the main influential factor for the dissociation between participants' attitudes and their practices. Therefore, development of a consensus for end-of-life care in ICUs in Egypt is mandatory. Also, training of physicians in ICUs on effective communication with patients' families and surrogates is important for planning of limitation of life-sustaining treatments.

The development of an individual differences end-of-life treatment preferences scale

The purpose of this study was to create an individual differences measure of end-of-life treatment preferences (EOLTPs). Young adults (n = 427) and older adults (n = 333) completed a survey. Results found that hope of recovery was an important factor in whether individuals preferred a given medical intervention. A single factor explained the majority of the variance in EOLTPs, and EOLTPs were distinct from more general attitudes about medical care. Older adults preferred less end-of-life medical intervention compared to younger adults. Overall, the results of the study support the use of an individual differences approach to measuring EOLTPs.

Power of the Past, Celebrate the Present, Force of the Future-Part 6: NASN-The Next 50 Years

NASN is celebrating 50 years of supporting the health needs of children and the practice needs of the school nurses who provide those services. This is the sixth and last in a series exploring the power of NASN's past, its celebration of the present and preparing for NASN to be a force of the future. This article builds on the historical precedents of NASN's history to develop a vision for its next 50 years. Examining the changing landscape of healthcare provides the outline of NASN's potential to advance child health.

The advocacy role of nurses in cardiopulmonary resuscitation

BACKGROUND

The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation.

RESEARCH OBJECTIVE

To explore what the nurse's advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain).

RESEARCH DESIGN

An exploratory critical qualitative study was conducted from October 2015 to March 2016. Thematic analysis was used to analyse the data.

PARTICIPANTS

Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5).

ETHICAL CONSIDERATIONS

Approval was obtained from the Basque Country Clinical Research Ethics Committee.

FINDINGS

Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns.

DISCUSSION

The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses' advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team.

CONCLUSION

This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians.

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose

Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown.

Methods

In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis.

Results

Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former.

Conclusion

Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5231-8) contains supplementary material, which is available to authorized users.

Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study

OBJECTIVE

To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission.

STUDY DESIGN

Prospective multicenter study.

SETTING

Eleven ICUs.

PATIENTS

All patients who died and/or had limitations on life support after ICU admission during a four-month period.

VARIABLES

Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission.

RESULTS

3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5).

CONCLUSION

Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.

How acceptable is paternalism? A survey-based study of clinician and nonclinician opinions on paternalistic decision making

We conducted an empirical study to explore clinician and lay opinions on the acceptability of physician paternalism. Respondents read a vignette describing a patient with brain hemorrhage facing urgent surgery that would be lifesaving but would result in long-term severe disability. Cases were randomized to show either low or high surrogate distress and certain or uncertain prognosis, with respondents rating the acceptability of not offering brain surgery. Clinicians (N = 169) were more likely than nonclinicians (N = 649) to find the doctor withholding surgery acceptable (30.2% vs. 11.4%, p ≤ 0.001). Among clinicians, the doctor withholding surgery was more acceptable when prognosis was certain to be poor (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.04, 4.01). There was no effect of surrogate distress on clinician ratings. Responses among lay public were more variable. Given the differences in attitudes across clinicians and lay public, there is an ongoing need to engage stakeholders in the process of end-of-life decision making.

US Physicians' Opinions about Distinctions between Withdrawing and Withholding Life-Sustaining Treatment

Decisions to withhold or withdraw life-sustaining treatment (LST) precede the majority of ICU deaths. Although professional guidelines generally treat the two as ethically equivalent, evidence suggests withdrawing LST is often more psychologically difficult than withholding it. The aim of the experiment was to investigate whether physicians are more supportive of withholding LST than withdrawing it and to assess how physicians' opinions are shaped by their religious characteristics, specialty, and experience caring for dying patients. In 2010, a survey was mailed to 2016 practicing US physicians. Physicians were asked whether physicians should always comply with a competent patient's request to withdraw LST, whether withdrawing LST is more psychologically difficult than withholding it, and whether withdrawing LST is typically more ethically problematic than withholding it. Of 1880 eligible physicians, 1156 responded to the survey (62%); 93% agreed that physicians should always comply with a competent patient's request to withdraw LST. More than half of the physicians reported that they find withdrawing LST more psychologically difficult than withholding it (61%), and that withdrawing LST is typically more ethically problematic (59%). Physician religiosity was associated with finding withdrawal more ethically problematic, but not with finding it more psychologically difficult. Physicians working in an end-of-life specialty and physicians with more experience caring for dying patients were less likely to endorse either a psychological or an ethical distinction between withdrawing and withholding LST. Most US physicians find withdrawing LST not only more psychologically difficult, but also more ethically problematic than withholding such treatment. Physicians' opinions are to some extent shaped by their religious characteristics, specialty, and levels of experience caring for dying patients.

Ethically Relevant Differences in Advance Directives for Psychiatric and End-of-Life Care

BACKGROUND

Psychiatric advance directives (PADs) represent a shift from more coercive to more recovery-oriented care and hold the promise of empowering patients while helping fill the gap in treatment of non-dangerous patients lacking decision-making capacity. Advance directives for end-of-life and psychiatric care share an underlying rationale of extending respect for patient autonomy and preventing the harm of unwanted treatment for patients lacking the decision-making capacity to participate meaningfully in planning their care.

OBJECTIVE

Ethically relevant differences in applying advance directives to end-of-life and psychiatric care are discussed.

DESIGN

These differences fall into three categories: (1) patient factors, including decision-making capacity, ability to communicate, and prior experience; (2) decisional factors, including expected outcome and the nature of the decisions; and (3) historical-legal precedent.

RESULTS

Specific recommendations are offered.

CONCLUSIONS

Clinicians need to appreciate the ethical implications of these differences to effectively invoke PADs or assist patients in creating PADs.

Decisiones sobre el soporte vital: aspectos éticos objetivos y subjetivos

Los avances en biomedicina amplían cada vez más las posibilidades de curar a enfermos críticos. Las decisiones sobre terapias por aplicar deben tener presente el riesgo de caer en el llamado “encarnizamiento terapéutico”. Aunque ya se ha escrito bastante sobre los criterios básicos que se deben tener en cuenta, aún quedan numerosas dudas a la hora de tomar las decisiones. Un aspecto no menor es la necesidad de objetivar los distintos elementos por ponderar, sin olvidar que hay aspectos subjetivos que son muy importantes. En el presente artículo se presenta una manera de combinar los aspectos objetivos y subjetivos, para llegar a un equilibro adecuado y práctico, que sea razonable y respete la autonomía del paciente.

Limitation of care orders in patients with a diagnosis of dementia

The prevalence of dementia is growing with an ageing population. Most persons with dementia die of acute illness and many are hospitalised at the end of life. In the acute hospital setting, limitation of care orders (LCOs) such as Do Not Attempt CPR and Physician Orders For Life Sustaining Treatment (POLST), appear to be underused in patients with dementia. These patients receive the same aggressive life-prolonging therapies as any other patient, despite drastically higher mortality. However, limitation of care orders in patients with dementia is not addressed by current guidelines or policies. Systems and processes for obtaining and documenting LCO need improvement at the individual, organisational and societal level. The issue is controversial amongst the public and poorly understood by clinicians. Balanced and empathetic decision-making requires an individualised approach and recognition of the complexities (legal, ethical and clinical) of this issue. We examine the domains of: (a) treatment effectiveness, (b) burden of care and quality of life and (c) patient autonomy and capacity.

History of brain death as death: 1968 to the present

The concept of brain death was formulated in 1968 in the landmark report A Definition of Irreversible Coma. While brain death has been widely accepted as a determination of death throughout the world, many of the controversies that surround it have not been settled. Some may be rooted in a misconstruction about the history of brain death. The concept evolved as a result of the convergence of several parallel developments in the second half of the 20th century including advances in resuscitation and critical care, research into the underlying physiology of consciousness, and growing concerns about technology, medical futility, and the ethics of end of life care. Organ transplantation also developed in parallel, and though it clearly benefited from a new definition of death, it was not a principal driving force in its creation. Since 1968, the concept of brain death has been extensively analyzed, debated, and reworked. Still there remains much misunderstanding and confusion, especially in the general public. In this comprehensive review, I will trace the evolution of the definition of brain death as death from 1968 to the present, providing background, history and context.

A prospective determination of the incidence of perceived inappropriate care in critically ill patients

BACKGROUND

Health care providers' perceptions regarding appropriateness in end-of-life treatments have been widely studied. While nurses and physicians believe that rationing and other cost-related practices sometimes occur in the intensive care unit (ICU), they allege that treatment is often excessive.

OBJECTIVE

To prospectively determine the incidence and causes of health care providers' perceptions regarding appropriateness of end-of-life treatments.

METHODS

The present prospective study collected data from patients admitted to the medical-surgical trauma ICU of a 30-bed, Canadian teaching hospital over a three-month period. Daily surveys were completed independently by bedside nurses, charge nurses and attending physician.

RESULTS

In total, 5224 of 6558 expected surveys (representing 294 patients) were analyzed, yielding a response rate of 79.7%. The incidence of perceived inappropriate care in the present study was 6.5% (19 of 294 patients), with ongoing treatment for >2 days after this determination occurring in 1% (three of 294 patients). However, at least one caregiver perceived inappropriate care at some point in 110 of 294 (37.5%) patients. In these cases, in which processes to address care were not already underway, respondents believed that important issues resulting in provision of inappropriate treatments included patient-family issues and communication before or in the ICU. Caregivers did not know their patients' wishes 22% (1129 of 5224) of the time.

CONCLUSIONS

Although ongoing inappropriate care appeared to be a rare occurrence, the issue was a concern to at least one caregiver in one-third of cases. Public awareness for end-of-life issues, adequate communication, and up-to-date knowledge and practice in determining the wishes of critically ill patients are potential target areas to improve end-of-life care and reduce inappropriate care in the ICU. A daily, prospective survey of multidisciplinary caregivers, such as the survey used in the present study, is a viable and valuable means of determining the scope and causes of inappropriate care in the ICU.

Conflicts and communication gaps in the intensive care unit

PURPOSE OF REVIEW

Conflicts occur frequently in the ICU. Research on ICU conflicts is an emerging field, with only few recent studies being available on intrateam and team-family conflicts. Research on communication in the ICU is developing at a faster pace.

RECENT FINDINGS

Recent findings come from one multinational epidemiological survey on intrateam conflicts and one qualitative study on the causes and consequences of conflicts. Advances in research on communication with families in the ICU have improved our understanding of team-family and intrateam conflicts, thus suggesting targets for improvement.

SUMMARY

Data about ICU conflicts depend on conflict definition, study designs (qualitative versus quantitative), patient case-mix, and detection bias. Conflicts perceived by caregivers are frequent and consist mainly in intrateam conflicts. The two main sources of conflicts in the ICU are end-of-life decisions and communication issues. Conflicts negatively impact patient safety, patient/family-centered care, and team welfare and cohesion. They generate staff burnout and increase healthcare costs. Further qualitative studies rooted in social-science theories about workplace conflicts are needed to better understand the typology of ICU conflicts (sources and consequences) and to address complex ICU conflicts that involve systems as opposed to people. Conflict prevention and resolution are complex issues requiring multimodal interventions. Clinical research in this field is insufficiently developed, and no guidelines are available so far. Prevention strategies need to be developed along two axes: improved understanding of family experience, preferences, and values, as well as evidence-based communication may reduce team-family conflicts and organizational measures including restoring leadership, multidisciplinary teamwork, and improved communication within the team may prevent intrateam conflicts in the ICU.

[A review of bioethics in the Intensive Care Unit: The autonomy and role of relatives and legal representatives]

In recent decades we have witnessed a change in mentality in which patient autonomy has reached significant preponderance, with informed consent as the prime example. The approach in situations where the patient cannot make decisions varies from one country to another, affording greater or lesser importance to the wishes of the family when a surrogate has not been designated. Several studies show discrepancies between the decisions of patients and that the decisions which their surrogates have taken for them. We review concepts such as greatest benefit, evaluate the potential limitations of advance care directives, and consider different options when the action or treatment proposed by professionals comes into conflict with the ideas expressed by the patient's family or surrogates, and which has led to different legally sanctioned solutions in some regions.

ICU research: the impact of invasiveness on informed consent

PURPOSE

Studies into the preferences of patients and relatives regarding informed consent for intensive care unit (ICU) research are ongoing. We investigated the impact of a study's invasiveness on the choice of who should give consent and on the modalities of informed consent.

METHODS

At ICU discharge, randomized pairs of patients and relatives were asked to answer a questionnaire about informed consent for research. One group received a vignette of a noninvasive study; the other, of an invasive study. Each study comprised two scenarios, featuring either a conscious or unconscious patient. Multivariate models assessed independent factors related to their preferences.

RESULTS

A total of 185 patients (40 %) and 125 relatives (68 %) responded. The invasiveness of a study had no impact on which people were chosen to give consent. This increased the desire to get more than one person to give consent and decreased the acceptance of deferred or two-step consent. Up to 31 % of both patients and relatives chose people other than the patient himself to give consent, even when the patient was conscious. A range of 3 to 17 % of the respondents reported that they would accept a waiving of consent. Younger respondents and individuals feeling coerced into study participation wanted to be the decision makers.

CONCLUSIONS

Study invasiveness had no impact on patients' and relatives' preferences about who should give consent. Many patients and relatives were reluctant to give consent alone. Deferred and two-step consent were less acceptable for the invasive study. Further work should investigate whether sharing the burden of informed consent with a second person facilitates participation in ICU research.

Legal aspects of end-of-life care

Critical care nurses are essential members of the health care team and often assist patients and patients' families who are facing end-of-life concerns. In that role, a nurse needs an understanding of many important factors, including legal implications associated with the end of life. Since the 1970s, courts have decided several cases that have established legal principles in end-of-life care. Courts have found that competent adults have the right to refuse or discontinue medical interventions. For incompetent adults and children, decisions are made by a surrogate. In the absence of an advance directive or documentation of goals of care, the surrogate, in collaboration with the medical team, determines a plan of care, including decisions about end-of-life care. When issues of medical futility occur, attempts to work with patients and their families should be undertaken, but if the dispute cannot be resolved, a transfer in care may be the only option.

Ethical conflicts with hospitals: the perspective of nurses and physicians

Nurses and physicians may experience ethical conflict when there is a difference between their own values, their professional values or the values of their organization. The distribution of limited health care resources can be a major source of ethical conflict. Relatively few studies have examined nurses' and physicians' ethical conflict with organizations. This study examined the research question 'What are the organizational ethical conflicts that hospital nurses and physicians experience in their practice?' We interviewed 34 registered nurses, 10 nurse managers, and 31 physicians as part of a larger study, and asked them to describe their ethical conflicts with organizations. Through content analysis, we identified themes of nurses' and physicians' ethical conflict with organizations and compared the themes for nurses with those for physicians.

Shaping patients' decisions

Many physicians struggle to strike an acceptable balance between respecting patient autonomy and guiding patients' decisions toward what is in their best interests based on their expressed values and long-term goals. Over the past 40 years, the ethical principle of respect for autonomy has gained primacy in Western medicine, but judgments about the appropriate dose of influence on patient decisions have been clouded by misconceptions about patient autonomy. In this article, we consider three such misconceptions with the goal of helping physicians to optimally promote their patients' interests.

International dialogue on end of life: challenges in the UK and USA

AIM

The aim of this paper was to increase international collaboration on end of life care (EoLC) in critical care. Objectives included highlighting key challenges for critical care nurses in EoLC through a transcribed interview between a clinician, an educationalist and a researcher who all hold an EoLC focus.

BACKGROUND

EoLC continues to hold high profile within international health care arenas, including critical care units. Whilst end of life care remains well debated, it still presents many challenges for everyday practitioners. Dialogue with international colleagues and disciplines may provide opportunity for further understanding of this complex and sensitive area.

CONCLUSIONS

A key issues to arise from this venture of shared learning was that futility of treatment is problematic for all. This is further complicated in the USA where the concept of (family) autonomy strongly shapes EoLC decision making.

RELEVANCE TO CLINICAL PRACTICE

This paper demonstrates that there are opportunities for nurses within health care teams which could be addressed through education and professional development initiatives. Furthermore, knowledge from other disciplines can provide a useful lens through which to improve our understanding of EoLC.

Consent issues in neurology

The requirement that doctors obtain valid consent from patients before providing medical treatment has long been ingrained in both legal doctrine and medical ethics. We summarize the foundations of the informed consent doctrine and discuss the recent evolution in thinking about consent and medical decision making. We show how consent has evolved from physicians merely providing patients information to shared decision making between patients and physicians. We then address three specific examples of situations common in neurological practice that pose challenges in obtaining valid consent: the administration of intravenous tPA following ischemic stroke, consideration of carotid endarterectomy for carotid artery stenosis, and implementation of do-not-resuscitate orders.

[Ethics of the cardiopulmonary resuscitation decisions]

Cardiopulmonary Resuscitation (CPR) must be attempted if indicated, not done if it is not indicated or if the patient does not accept or has previously rejected it and withdrawn it if it is ineffective. If CPR is considered futile, a Do-Not-Resuscitate Order (DNR) will be recorded. This should be made known to all physicians and nurses involved in patient care. It may be appropriate to limit life-sustaining-treatments for patients with severe anoxic encephalopathy, if the possibility of clinical evolution to brain death is ruled out. After CPR it is necessary to inform and support families and then review the process in order to make future improvements. After limitation of vital support, certain type of non-heart-beating-organ donation can be proposed. In order to acquire CPR skills, it is necessary to practice with simulators and, sometimes, with recently deceased, always with the consent of the family. Research on CPR is essential and must be conducted according to ethical rules and legal frameworks.

How I conduct the family meeting to discuss the limitation of life-sustaining interventions: a recipe for success

The meeting with the family of a hospitalized patient dying with advanced cancer or hematologic disease in which the limitation of life-sustaining interventions is discussed can be a challenge, particularly for junior physicians. A successful conclusion to this discussion involves an outcome in which the family, without coercion or manipulation, comes to accept that the appropriate care has been provided to their loved one, while the caregivers are enabled to provide care that is goal-directed and patient-centered. This type of result can be achieved through an approach in which patient-focused recommendations are offered in the context of diligent efforts to establish and sustain trust, thoughtful preparation, and respectful discussions with the family.

Compromised autonomy and the seriously ill patient

Respect for patient autonomy has become the preeminent principle of medical ethics, to the point that tools have been developed, such as instructive directives, in an attempt to preserve a semblance of autonomy even when it has become clearly and irretrievably lost. Much of the practice around the respect for autonomy, however, mistakenly supposes that the capacity for autonomous choice is an all-or-nothing proposition. But seriously ill patients may retain some ability to participate in discussions of medical care yet have their autonomy profoundly compromised by physical duress, cognitive dysfunction, or delirium. The choices of individuals with compromised autonomy do not carry the same moral weight as those of the fully autonomous. Clinicians, therefore, cannot rely on such choices for guiding medical decisions and are obligated to evaluate them more fully before acting. We argue that clinicians should compare the choices of individuals with compromised autonomy to a medical assessment of the patient's best interest. When the patient's choice and the best-interests assessment are discordant, acting in the patient's best interest may, at times, rightly override the requests of the patient. Such an approach, under a tightly constrained set of circumstances, would permit both the provision and the withholding of medical interventions despite patient requests to the contrary.

End-of-life decision making in the intensive care unit

Increasingly in the United States and other countries, medical decisions, including those at the end of life, are made using a shared decision-making model. Under this model, physicians and other clinicians help patients clarify their values and reach consensus about treatment courses consistent with them. Because most critically ill patients are decisionally impaired, family members and other surrogates must make end-of-life decisions for them, ideally in accord with a substituted judgment standard. Physicians generally make decisions for patients who lack families or other surrogates and have no advance directives, based on a best interests standard and occasionally in consultation with other physicians or with review by a hospital ethics committee. End-of-life decisions for patients with surrogates usually are made at family conferences, the functioning of which can be improved by several methods that have been demonstrated to improve communications. Facilitative ethics consultations can be helpful in resolving conflicts when physicians and families disagree in end-of-life decisions. Ethics committees actually are allowed to make such decisions in one state when disagreements cannot be resolved otherwise.