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Pulmonary & Critical Care Bulletin
Vol. VII, No. 3, July 15, 2001
In this issue :
From Editor's Desk
ETHICAL AND LEGAL ISSUES IN INTENSIVE CARE UNITS
Bio-ethics involve morality and behaviour while managing a patient. Unethical behaviour may/may not be punishable by law, but is condemned by the profession and the colleagues. Some of the important issues are tabulated below:
Note: An Ethical Committee of the institution should be in place to form strategies and resolve conflicts at any level, if required.
FUNDAMENTAL ETHICAL PRINCIPLES
1. Patient's Autonomy: Relates to decision for continuation or withdrawl of therapy; taken
2. Beneficence: To do the best to benefit the patient either actively or passively by not doing any harm.
3. Justice: Involves fairness in distribution of resources. It is based on following theories:
i) Egalitarian theory: All patients having same medical need should get equal resources It is not always possible to follow this practice in developing countries.
iii) Liberatarian theory: Allocation according to paying capacity e.g. private Health Insurance
PRINCIPLES OF MICRO ALLOCATION IN ICU
1. All critically ill patients do not merit admission to ICU. Factors considered are:
2. All those who merit admission may not be accommodated due to scarcity of beds.
5. Vulnerable section of the community should be protected by additional care e.g. premature infants, elderly etc.
6. Benefit of ICU care should be evaluated on the basis of medical indication, patient's autonomy, overall value to the individual and the society.
7. Limit resources to a patient who is unfairly consuming and therefore compromising the same to other patients.
8. Allocation rule should be governed by the Institution and not by an individual.
Withholding/withdrawing life support- Do Not Resuscitate (DNR)
Legally speaking, withholding and withdrawing have similar implications.
1. When resuscitative measures are futile: Decision is taken by the physician after explaining it to the relatives. He is not bound to abide by the decision of the relatives.
2. When patient had wanted DNR by advanced directives (written/verbal) or the surrogate decides not to sustain.
* When patient's preference is unknown, surrogate cannot decide - physician has to decide for DNR. It is better to err on sustaining than abandoning.
*For decision making - Patient must be legally competent (adult); must have the capacity to comprehend, without psychiatric problem and well informed.
DIFFERENT LEVELS OF DNR & ITS GOALS
Carrying out DNR:
When to label a life support as futile ?
not achieve nor expected to restore vital functions
INFORMED CONSENT: Required for
* Comprises members from all strata (including laymen) so that any specific issue can be solved by consensus
1. Lanken PN, Ethics in the ICU: Fishman's Pulmonary Diseases and Disorders, Vol. 2, 1998.
Dr. Asutosh Ghosh,
Dr. Asutosh Ghosh
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