Ethical Considerations in Critical Care Decision Making

Introduction

Trust and relationship are the key factors that build a strong bond between the doctor and the patient. Medical ethics deals with the ethical principles that should be followed while providing medical care and treatment to a patient by a doctor or any other healthcare professional. An intensive care unit (ICU) is a hospital unit where critically injured or ill patients get admitted. It is a place where ethical conflicts can undoubtedly take place. ICU doctors and other healthcare professionals treating and caring for critical patients often encounter ethical difficulties in an intensive care unit.

What Are the Major Reasons for Ethical Clashes in an ICU?

Ethical conflicts can certainly take place in an intensive care unit. One or more of the following reasons may be the reasons for such conflicts:

• An ICU admission generates a high-pressure environment due to two reasons: the admissions and treatments offered can be expensive, and the patient will be seriously ill.

• Requirements of ICU beds and limitations for the same can also create conflicts.

• Life and death decisions are usually made in a hospital’s intensive care unit. This will also be driven by emotions, tensions, and confusion.

• Whether or not to admit a patient to an intensive care unit may not be decided based on the ideal principles. It may get influenced by the concepts of the bystanders, patients, management, etc.

• Under certain circumstances, the ICU doctors may get subjected to pressure from the management or other reasons and may get forced to act opposite to what is taught under medical ethics. For example, limited resources in an ICU may force a doctor to discharge a patient from the intensive care unit and to shift to the general ward before complete recovery.

What Is an Ethical Dilemma?

Ethical decisions cannot be made with ease. Morally considered, if there are chances of multiple correct treatment options or actions that cannot be performed, it is considered as a state of an ethical dilemma. A dilemma occurs when the decision-making process gets tedious due to the presence of multiple solutions. Decisions and actions following an ethical dilemma can lead to right or wrong. Conflicts may develop between the intensive care unit healthcare members in the case of an ethical dilemma. This may lead to patient suffering and ethical violations. Identifying the health condition of the patient after proper diagnostic procedures is the preliminary step while making ethical decisions in an intensive care unit.

What Are the Types of Ethical Conflicts That Arise in an ICU?

Ethical conflicts can happen while caring for a critically injured or ill patient due to many reasons:

• Lack of Knowledge: Ethical clashes probably develop if the healthcare person lacks adequate knowledge or education regarding ethical practices. This could make the doctor flexible while making decisions regarding a critically ill patient. Such doctors, nurses, or other healthcare professionals may get forced or influenced by the opinions put forth by the management or the bystanders.

• Command From the Supremacy: Doctors in a hospital may get commanded by the management or the authority to act according to their wishes. This may also be due to inadequate facilities in the intensive care units.

• Non-availability of Affordable Treatments: Critical or emergency treatments offered in hospitals can be expensive. The assistance provided by the machines or devices may not be affordable for many people. This may lead the families or bystanders to opt for general wards instead of intensive care units.

What Are the Ethical Practices to Be Considered in Critical Care?

The following points should be considered for enabling better ethical practices while treating a critical patient:

• Providing training programs to healthcare providers, especially intensive care unit doctors and nurses, is important to update them and improve their level of education or knowledge.

• Admissions to intensive care units should only be made after being observed and consulted by the critical care team doctors and healthcare professionals.

• It is essential to let the patient, if conscious, and the bystanders know and learn about the illness and the prognoses. This will provide psychological support to the patient and helps them make efficient decisions. Thus, the quality of life of the patient gets improved.

• The doctors can discuss with the patients or bystanders the best possible treatment goals. Shared decision-making is an effective tool for valuing the patient’s interest. It will integrate the knowledge and experience of the ICU doctors with the state, goals, and interests of the patient.

• Critical care decision-making should depend on the type and severity of the patient’s medical condition. It should be based on the organ impairment developed in the patient. The functional capacity of the patient, the duration of assistance required, and the need for further intensive therapies should also play a role in decision-making.

• The risks and benefits of intensive care unit treatments should be explained to the patient and bystanders before admission. This may help the family and the doctors understand the person’s interests, which can be applied later for decision-making if the patient requires the assistance of a ventilator. Some patients do not wish to get ventilated in an ICU.

• Decisions related to CPR or cardiopulmonary resuscitation should be made on the basis of the technique’s potential risks and benefits and the probable outcomes that could develop in the patient.

• The decisions regarding the usage of life-saving equipment should be made after proper discussion with the senior and experienced doctors.

What Are the Factors Indicating Good Ethical Practice in an ICU?

The following elements indicate a good ethical practice while treating a critically ill or injured patient:

• Careful observation of the patient before ICU admission.

• Assessing the medical condition of the patient after carrying out proper diagnostic steps.

• Planning the possible treatments based on the condition and capacity of the patient.

• Evaluating the benefits and risks of the treatments and care.

• Making the patient or the bystander understand the condition, available treatments, risks, and benefits.

• Considering the goals and interests of the patient and encouraging shared decision-making for further procedures.

• Decision-making can be conflictual, and the ICU doctor should be able to tolerate the same.

Conclusion

Ethical dilemmas are certain while treating critically injured or ill patients admitted to an ICU. Multiple barriers intensify the situation. The ICU healthcare professionals should be able to identify such factors to efficiently remove them by making the best decisions. Being empathetic, knowledgeable, and experienced helps the doctor resolve the conflicts that could develop in an ICU.