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Pulmonary & Critical Care Bulletin
Vol. VII, No. 3, July 15, 2001
In this issue :

From Editor's Desk

AEROSOL THERAPY
(Dr. Uma Maheswari,)

ONCE - DAILY ASTHMA PREVENTION THERAPY
(R. S. Bedi & U.S. Bedi)

16th Annual Meeting on Pulmonary and Critical Care Medicine
(Dr. S. K. Jindal)



Publihed under the auspices of:
Pulmonary C. M. E. Programme



Editorial Board :


Department of Pulmonary Medecine
Post Graduate Institute of Medical Education & Research (PGIMER) Chandigarh. INDIA-160012


Subscription :


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:
Point during the Course of illness Issues Who to make decision ?
1. Admission to ICU Whether to admit ? Hospital authority, by preformed strategy
.Physician - assessing medical indication and patient autonomy
. Patient/surrogate
2. Inside ICU Micro-allocation of apparatus, devices and other medical facilities . Physician
3. Patient on life support(s) which is/are beneficial ? To sustain or Do not resuscitate (DNR) .Patient 
. Surrogate 
. Physicians
4. Dying-efforts are futile DNR Physician
5. Dead . Diagnosis of death . Organ donation . . . . Autopsy Physician(s) 
Physician 
and Surrogate

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
i. either directly by patient by advanced directives, or
ii. by patient's close relatives/friends (surrogates)

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.
ii) Utilitarian theory: Utility of limited resources is maximized by distribution on the basis of priority.

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:
. Patient's interest
. Hospital policy
. Medical indications and criteria

2. All those who merit admission may not be accommodated due to scarcity of beds.
Solutions: . First come first serve
. Prioritisation
. Transfer of least sick patient from ICU to high dependency ward 3. All individuals' lives are equally valuable 4. Care in an emergency is a legal obligation, but in ICU this is controversial.

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.

Indications:

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

Level Interventions Goals
A All treatment continued except Cardiopulmonary Resuscitation (CPR) On cardiopulmonary arrest, CPR is not done. Only drug treatment may be undertaken.
B No additional treatment No CPR To maintain status quo treatment
C. Palliation only
All life sustaining treatments including artificial feeding and water - withdrawn
Nursing care; drug: Treatment for comfort e.g. analgesic

Carrying out DNR:

  • Order should be recorded in file.
  • IV sedation before removing from mechanical ventilation
  • Extubation by - physician/respiratory therapist/nurse
  • CPR as a "show" is not justified since this is a type of deception.

    When to label a life support as futile ?

  • No universal agreement
  • Physiologically futile means the measure does
    not achieve nor expected to restore vital functions
  • Should be judged by the physician

    INFORMED CONSENT: Required for

  • ICU admission
  • Sustaining/Withdrawing life support
  • Intervention
  • Autopsy
  • Organ donation for transplant

    ETHICAL COMMITTEE

    * Comprises members from all strata (including laymen) so that any specific issue can be solved by consensus
    * Former guidelines, resolves conflict
    * For all practical purpose, almost all conflicts can be resolved by discussion with relatives or surrogates. Rarely, judicial consultation is required.

    Further Reading

    1. Lanken PN, Ethics in the ICU: Fishman's Pulmonary Diseases and Disorders, Vol. 2, 1998.
    2. Brody H: Withdrawing intensive life sustaining treatment - Recommendations for compassionate clinical management: NEJM 336; 652-657, 1997.
    3. Raffin TA: Perspectives on Clinical Medical Ethics: Principles of Critical Care, JB Hall, 1992, 2185-2204.

    Dr. Asutosh Ghosh,
    Senior Resident (Pulmonary Medicine),
    PGIMER, Chandigarh.

    Dr. Asutosh Ghosh



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