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 Emergency & First Aid

september 2012

Medical Ethics With Regards To ICU Patients

Dr Sudha Kansal
Medicalemergencies and treatment of critically ill patients are perhaps two situations where doctors, patients and patients’ relatives come face to face with medical ethics, more pressingly than other medical situations. An established way around it is perhaps easier said than done.

Senior politician and union minister Vilas Rao Deshmukh’s untimely death from multiple organ failure, recently, was one such instance. It brought to the fore our unforgivable systemic-inability to harness and reap the benefits of advanced medical care. To quote one news headline that reported on his missed opportunity for a dual organ transplant, the delay in could-have-been donors arriving at a decision and the lack of cadaver organs, “Transplant in time could have saved Vilas Rao Deshmukh”.

To generalise, ethics is the study of morality and moral reasoning, which helps us in deciding what we ought to do in circumstances where a choice must be made.

Four basic ethical principles in medicine:
  • Autonomy: The patient’s right to self-determination or the freedom to accept or refuse treatment.
  • Beneficence: Moral obligation of the physician to perform in favour of the patient’s welfare.
  • Non-maleficence: Avoidance of treatment, which can cause harm to the patient.
  • Justice: Expectation of society that everyone will be treated fairly.
While treating critically ill patients, seeking consent to treatment is an essential part of medical practice. The consent should be written after sourcing proper information and being convinced of it. Many of these patients won’t be in a condition to give consent. In such a case, the next of kin is the next legal guardian for obtaining consent. However, in a situation where emergency medical treatment that is necessary to restore and preserve the patient’s health is required, it can be administered without waiting for the consent.

End-Of-Life Care Issues

End-of-life care issues are important in this group of patients. In India, legal opinion and legislation relating to end-of-life care is scarce. It is rather disturbing that there is no clearly stated legal opinion regarding discontinuation of life support systems, even in brain dead patients. There are serious legal, moral and religious issues involved in the matter of limiting life support.

Withdrawing life support from a patient, who is unconscious of his existence and is also unconscious about either the continuance or the stoppage of medicines, is treated as an action taken in the overall interest of the patient himself. Courts have held that they have inherent power to exercise parens patriae jurisdiction in such cases, in the same way as in the case of minors, temple-deities, trusts and charities, and give appropriate directions to the doctors to continue or stop life support systems.

Advance medical directives and medical powers of attorney are not legal in India, as they can be easily abused and create unwanted litigation.

Counselling of ICU patients is as important, if not more, as the treatment of these critically ill patients. The goal is to convey information. This helps to add to the knowledge of the relatives, motivate them to act, clear their doubts and express their emotions. Interacting with the patient’s family is an integral part of caring for a critically ill patient. These families have a lot of anxiety, fear and anger and also suffer physical, mental and financial exhaustion. They want information about the patient’s condition, plan of treatment and prognosis of their dear one.

The doctor should provide them clear, accurate, timely and honest information in the language they understand. The relatives must follow the discipline of the hospital. Often, the deterioration in the patient’s condition is because of the nature of the disease and not due to the doctor’s fault. Thus the relatives must discuss their doubts with the doctor and clear them.

The doctor’s interaction with the patient’s family is an integral part of caring for the critically ill. These families have a lot of anxiety and also suffer physical, mental and financial exhaustion.

Guidelines For Counselling
On admission to ICU, there should be a meeting of the physician with the relatives, after assessment, to explain about the patient’s condition, plan of treatment, interventions planned and chances of recovery in simple terms. The physician-in-charge should counsel them daily and also whenever there is an unexpected change in the patient’s condition. ICU patients generally have a multidisciplinary team of doctors looking after them and the primary communication should be by the physician-in-charge.
While counselling the patient or relatives, many factors influence the understanding of the message. The counselling must be done in the language they understand and at the level of their understanding. The tone of voice, choice of words, the volume of speech and the body language should be appropriate to the situation. The relatives must be then encouraged to ask questions, which not only helps them to clear their doubts but also to judge whether the message has been understood clearly.

Communicating With Patients
Family members of critically ill patients have a strong desire for proximity to the patient. When relatives visit the patient, they should talk to the patient about the ICU environment, what is going on around, what is going on back home and so on. Competent communication is essential and has been shown to enhance the relatives’ satisfaction and the patient’s compliance with therapy.
Dr Sudha Kansal is Senior Consultant Respiratory & Critical Care, Indraprastha Apollo Hospitals, New Delhi .