Ethics at the bedside: A conversation with Hans-Peter de Ruiter, PhD, RN; Deborah Freeman, BSN, RN; Ronda Hughes, PhD, RN, MHS, FAAN; and Richard Sellers, MDiv, MA (original) (raw)
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Critical Conversations: When the Bedside Clinician Calls for Clinical Ethics
ICU Director, 2010
Background: Sharon is a 56-year-old woman who has been complaining of bloating and discomfort for years. While descending steps from her hillside home, she recently fell and fractured her pelvis. A CT of the pelvis revealed a large ovarian mass with smaller masses in the peritoneum, and studies of the chest and upper abdomen revealed masses in the liver and lung. A recent biopsy confirmed poorly differentiated cells. She was diagnosed with metastatic ovarian carcinoma and managed conservatively for the pelvic fracture. Until last month Sharon ran a preschool, but she has been homebound for weeks.
Ethics in the Intensive Care Unit
Critical Care Clinics, 1997
Ethical considerations in the adult and pediatric intensive care unit (ICU) often involve moments of crisis marked by disagreement over decisions, such as whether to resuscitate a patient; to extubate and allow the patient to die; to hasten actively a patient's death; to withhold or withdraw unilaterally so-called futile treatment over a patient's or family's objections; or to allocate limited or expensive resources, such as extracorporeal membrane oxygenation or the last ICU bed. The expansion of technology (such as nitric oxide, high-frequency oscillatory ventilation, and partial liquid ventilation) combined with the awareness of biologic, economic, and ethical limits to applying that technology may lead to uncertainty and conflict when faced with our apparent inability to restore a patient to his or her previous state of personal well-being. Such questions are important; however, we often are left with the false impression that ethics only comes into play in these problematic situations existing at the margins of our technical skill, rather than in our everyday care of critically ill patients. As such, ethics becomes identified with an ethics committee or consultant called only when we have failed A previous version of this article was presented to the 1997 Current Concepts in Pediatric Critical Care, sponsored by the Society of Critical Care Medicine, and held in San Diego, California.
The difficulties that exist putting ethical theory into practice in critical care
Clinical Intensive Care, 2006
At a recent General Medical Council conference it was suggested by Dame Janet Smith, author of the Shipman inquiry report, that medical students should be assessed on their understanding of ethical principles (GMC Education Conference, May 9, 2005). Indeed, issues of medical ethics have recently made headline news around the world. In England, the right of a patient with progressive cerebellar ataxia to compel doctors to continued feeding for so long as he wishes is under appeal (Dyer, C. The Guardian, London, May 16th, 2005). In America, the recent death following withdrawal of feeding from Terri Schiavo, who was in a persistent vegetative state since 1990, taxed doctors, legislators and politicians up to the White House (Stolberg, SG, The New York Times, April 1, 2005). While such high profile cases arise exceptionally, critical care routinely involves ethical considerations, either implicitly or explicitly. This review describes various ethical principles commonly employed in relation to critical care, and the common problems with their application in the practice of managing the critically ill patient.
Ethics and palliative care consultation in the intensive care unit
Critical Care Clinics, 2004
Mr. Smith is a ventilator-and feeding tube-dependent 76-year-old Black male suffering from advanced Parkinson's-like symptoms. Before his admission to the intensive care unit (ICU), Mr. Smith developed aspiration-induced pneumonia, resulting in placement on vent support and the administration of tube feeding. After 7 weeks in the medical ICU, he is not responding well to medication and his condition is deteriorating. Mr. Smith has moderate to severe dementia, and periodically lapses in and out of consciousness. Mr. Smith's wife of 5 years has been actively involved in care decisions, as has his 27-year-old daughter from a previous marriage. Mr. Smith also has a 46-year-old son who lives out of state, and has not been reachable despite numerous attempts by family and social work. Mr. Smith is faced with the prospect of placement in a skilled nursing facility, with continued tube feeding and ventilator support, or withdrawal of life support in the ICU, with the likelihood of imminent death. Mr. Smith periodically appears to be uncomfortable, as he sometimes winces and grimace when suctioned. Mr. Smith's wife and daughter both want continued aggressive care in the ICU setting, resisting nursing home placement. The ICU attendant, Dr. Jones, thinks that Mr. Smith should be made do-not-resusitate, and that all technological support should be withdrawn. He believes that the focus of care should be on comfort. Dr. Jones and Mrs. Smith have had several tense discussions about this, and are now barely speaking to each other.
On the Current State of Clinical Ethics
Pain Medicine, 2001
Practitioners of pain medicine and palliative care may already be quite familiar with clinical ethics, yet still uncertain about the precise nature of the field and the scope of its activities. Clinical ethics is centrally concerned with the ethics of the encounter between the healthcare professional and the patient in clinical care settings. It is thus a subset of bioethics, and distinct from research ethics and organizational ethics. The various ways of organizing teaching activities, research programs, and case consultations in clinical ethics are described and critiqued. The author describes some new and emerging ideas and practices in clinical ethics, speculates about future directions for the field, and concludes with a call for greater collaboration between practitioners of pain medicine and clinical ethicists.
BMC Medical Ethics, 2018
Background: DNR decisions are frequently made in oncology and hematology care and physicians and nurses may face related ethical dilemmas. Ethics is considered a basic competence in health care and can be understood as a capacity to handle a task that involves an ethical dilemma in an adequate, ethically responsible manner. One model of ethical competence for healthcare staff includes three main aspects: being, doing and knowing, suggesting that ethical competence requires abilities of character, action and knowledge. Ethical competence can be developed through experience, communication and education, and a supportive environment is necessary for maintaining a high ethical competence. The aim of the present study was to investigate how nurses and physicians in oncology and hematology care understand the concept of ethical competence in order to make, or be involved in, DNR decisions and how such skills can be learned and developed. A further aim was to investigate the role of guidelines in relation to the development of ethical competence in DNR decisions. Methods: Individual interviews were conducted with fifteen nurses and sixteen physicians. The interviews were analyzed using thematic content analysis. Results: Physicians and nurses in the study reflected on their ethical competence in relation to DNR decisions, on what it should comprise and how it could be developed. The ethical competence described by the respondents related to the concepts being, doing and knowing. Conclusions: In order to make ethically sound DNR decisions in oncology and hematology care, physicians and nurses need to develop appropriate virtues, improve their knowledge of ethical theories and relevant clinical guidelines. Ethical competence also includes the ability to act upon ethical judgements. Continued ethical education and discussions for further development of a common ethical language and a good ethical working climate can improve ethical competence and help nurses and physicians cooperate better with regard to patients in relation to DNR decisions, in their efforts to act in the best interest of the patient.
BMC medical ethics, 2001
A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems.