Introduction
Nowadays, many situations occur when healthcare professionals have to make difficult decisions according to various ethical principles, which is not always straightforward due to the specificity of the medical care field.
The corresponding difficulties can be exceptionally sharp within the critical care setting because treating patients with life-threatening illnesses can be ethically challenging. This paper aims to discuss particular issues related to ethical principles and legal concepts present in the modern setting of an intensive care unit. For these purposes, various ethical concerns and ideas of end-of-life care will be addressed, along with the associated cultural considerations. In addition, the presentation applies components of a specific systematic decision-making model in the intensive care unit and describes a particular ethical situation that might occur in the critical care setting.
Ethical principles associated with critical care
Healthcare professionals follow several important principles when they face a challenging ethical dilemma. Although there are difficult situations that require making hard decisions that might take more than these principles, they are usually a part of the decision-making process. According to Cook et al. (2021), the first principle is that medicine, especially within the acute care setting, should always aim to save more lives of years of life. The following essential principle is to respect patients’ views on the quality of their lives since clinicians’ views on that issue should not be incorporated as their judgment is not always reliable (Cook et al., 2021).
The researchers also state that age cannot be a sole determinant of priorities when it comes to admission to ICU, and the duration of ICU treatment for a patient should not negatively impact the availability of necessary resources for other patients (Cook et al., 2021). Finally, the ICU framework should always respond to current scientific evidence, which is constantly changing (Cook et al., 2021). Following these ethical principles is an effective decision-making method in the acute care setting.
Legal concepts associated with acute care
Particular situations in critical care require legal opinions to solve specific ethical issues that cannot be adequately addressed without law interference. An example of such a situation is the necessity to remove a patient from an ICU bed because another patient also needs it. According to Cook et al. (2021), that may be ethically justifiable but requires a legal opinion to decide whether it should be done or not. Another similar situation occurs when clinicians or the patient and their family members cannot agree on performing a specific action (Cook et al., 2021). Finally, patients might lack decision-making capacity due to various circumstances usually associated with their health condition.
In that case, clinicians may contact people close to the patient and a legal welfare proxy to make a decision appropriate for the overall benefit of the patient (Cook et al., 2021). That way, some challenging ethical issues can be solved with the help of legal concepts applicable in the acute care setting.
Decision-making models in the critical care setting
In the acute care setting, decision-making is a step-by-step process, and it requires the highest possible accuracy when it comes to solving ethical issues. Several decision-making models are described in the current research and aim to help healthcare professionals address the difficulties associated with healthcare delivery, including the ethical ones. These models have been developed because healthcare professionals nowadays have to operate in a complex system that is rapidly increasing (Guo, 2020). For instance, the military model occurs in five steps which imply defining the objective and discussing all the available resources (Guo, 2020).
The parliamentary model is similar to the previous one but more complicated and occurs in 8 steps, yet the researchers claim both models lack specificity (Guo, 2020). Therefore, a complex model known as QUICK has been developed that combines elements of the military and parliamentary models and focuses on making decisions quickly and executing action (Guo, 2020). However, the models described above lack detail when identifying the specific activities required for the models’ application.
DECIDE: a model for effective decision-making
An innovative decision-making model can be used when solving ethical issues in the acute care setting. The model under discussion is called DECIDE, which is the acronym for specific actions taken in the decision-making process when the model is applied (Guo, 2020). The first required step is defining the problem because it is essential to determine the barriers to solving a specific issue before healthcare managers can make a decision.
The second step is establishing the criteria, namely identifying what should be achieved and avoided while solving an ethical issue in the critical care setting. The third step is considering all the alternatives to define possible choices to meet the established criteria. The fourth step is identifying the best alternative to make an ethically justifiable decision. The final steps of the model are rather technical as they imply developing and implementing the plan and then evaluating and monitoring the results of the decision made. This model is excellent for solving ethical problems in a critical care setting as it implies discussing all possible decisions and choosing the most appropriate one.
Ethical concerns related to end-of-life care
Many ethical concerns are associated with end-of-life care, and some of them are presented on this slide. According to Brooks et al. (2017), healthcare professionals in the intensive care unit often face many ethical challenges related to life-sustaining therapy and end-of-life decisions. One of the corresponding ethical concerns is the withdrawal of active treatment if the patient has little or no chance of recovery, and that withdrawal is one of the most common steps in end-of-life care (Brooks et al., 2017).
The discussion that occurs when end-of-life care has been initiated involves an interdisciplinary team of clinicians and the patient’s close people, primarily their family members (Brooks et al., 2017). A critical ethical concern, in this case, is understanding the patient’s wishes since patients cannot always express them clearly (Brooks et al., 2017). In other words, the decision-making process in end-of-life care is highly complex and challenging.
Legal concerns related to end-of-life care
Aside from ethical considerations, some significant legal concerns are associated with end-of-life care. For instance, a patient may lack the decision-making capacity to decide if they want to end their life forcefully (Cook et al., 2021). In this case, it requires legal opinion to analyze the necessity of end-of-life care initiation. Moreover, it is well-known that ending life-sustaining therapy is not globally legal, meaning that it is strictly prohibited in some countries (Cook et al., 2021). Finally, a patient’s physiology and comorbidity should be thoroughly investigated to decide whether the initiation of end-of-life care is justifiable (Cook et al., 2021). Otherwise, the activities related to end-of-life may be unjust or even illegal.
Concepts of end-of-life care
Aside from ethical considerations, there are several general concepts associated with end-of-life care. The first of them is palliative care, which implies treatment to ease the patient’s pain without curing the cause of the condition to support the patient and their family (Brooks et al., 2017). Another significant concept is communication and conflict resolution, which is considered critical in the transition from life-sustaining treatment to the initiation of end-of-life care (Brooks et al., 2017). As mentioned before, that is commonly associated with withdrawal from the therapy (Brooks et al., 2017). Clinicians usually discuss these concepts before patients are admitted to the intensive care unit.
Psychological support in end-of-life care
End-of-life care is a complicated and challenging process that is never simple for all the people involved. Therefore, they might need psychological support to help them through the dying process. The first person who requires psychological support is the patient since they are likely to die soon (Cook et al., 2021). The patient’s family members also might need professional psychological help as it is never easy for parents, children, and other relatives to lose a close person, especially when they have to participate in the decision-making process regarding end-of-life care (Cook et al., 2021).
Finally, the healthcare providers might often need psychological support as well because it can be highly challenging to make decisions on another person’s life and “pull the plug” (Cook et al., 2021). Overall, end-of-life care and the corresponding decisions are always complex, and the absence of psychological support can have severe consequences for everyone involved.
Cultural considerations in end-of-life care
In addition to general ethical principles applicable in most cases of end-of-life care, some patients may be a part of a culture with particular specificities regarding the related issues. According to Brooks et al. (2017), cultural considerations in end-of-life care include worldview and values, social circumstances, religion, and other elements. For instance, some people might consider life an essential value that they cannot refuse willingly, or their religion does not allow it. Social circumstances can also play a significant role in it is unacceptable for the patient to destroy their social boundaries by agreeing to end their life-sustaining treatment.
Cultural considerations in end-of-life care for clinicians
Everything described in the previous slide is applicable not only to patients but clinicians as well. Specific cultural differences between healthcare professionals might create various issues in end-of-life care. These include lack of acceptance within a multidisciplinary team, professional disagreements regarding decision-making, and communication issues that may negatively impact the patients’ outcomes (Brooks et al., 2017). Therefore, a high level of professionalism among clinicians involved in end-of-life care is necessary to keep the corresponding ethical discussions reasonable.
A specific ethical situation
There was a case in the practice of the author of this presentation when a critically ill patient with no chances of recovery asked his doctors to initiate end-of-life care. However, his wife, who was by his bed all the time, could not agree with such an outcome and was trying to avoid it. She was highly emotional, and it took much effort from her husband to ensure her that this was the right decision. Doctors who treated that patient were confused as they could not decide what to do. Finally, the decision to end the life-sustaining therapy was made, although it was difficult for the patient’s wife to accept.
Ethical issues: Experience and reflection
The author’s experience described in the previous section demonstrates the ethical challenges of end-of-life care and decisions. It will probably never be simple to decide which choices are the most appropriate in each ethically complex situation, especially in the critical care setting. The corresponding decision-making process may be complex even for nurses as they are a part of it since they care for their patients.
Conclusion
Ethical challenges often occur in the acute care setting, especially when it comes to end-of-life care. The decision-making process can be difficult for the patient, their family, and clinicians. It requires clinicians’ high professionalism and mutual efforts to deal with the ethical challenges in acute care.
References
Brooks, L. A., Manias, E., & Nicholson, P. (2017). Communication and decision-making about end-of-life care in the intensive care unit. American Journal of critical care, 26(4), 336-341. Web.
Cook, T., Gupta, K., Dyer, C., Fackrell, R., Wexler, S., Boyes, H., & Marden, B. (2021). Development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity: A discussion paper. Journal of medical ethics, 47(7), 456-463. Web.
Guo, K. L. (2020). DECIDE: A decision-making model for more effective decision making by health care managers. The health care manager, 39(3), 133-141. Web.