ASSIGNMENT ON

LEGAL AND ETHICAL ISSUES

IN INTENSIVE CARE

SUBMITTED TO SUBMITTED BY
Madam Nirupama Saha Swagata Mandal
Professor [Link]. Nursing 2nd year
College of Nursing College of Nursing
R. G. Kar Medical College and Hospital
R. G Kar Medical College and Hospital
INTRODUCTION:
Ethical Standards based on human principle of right & wrong and Legal Standards based on
written law. Ethical Decision Making emerged in the recent years as a major component of
health care for the critically ill patients. Ethical decision making refers to the process of
evaluating and choosing among alternatives in a manner consistent with ethical principles
Ethical principles are Autonomy, Patient's right to self determination, non maleficent, do no
harm, Beneficence, promoting good, Veracity, the obligation to tell the truth, Fidelity,
faithfulness to agreements & responsibilities, Justice, the fair allocation of medical resources.
Ethics are involved and/or influence by: LAWS, RELIGION, SCIENTIFIC STUDIES,
PHILOSOPHY, MORAL.

PRINCIPLES OF MEDICAL ETHICS:

Ethical principles are general statements about what types of actions are right or wrong.
Including the principles of Autonomy, Beneficence, Non-maleficience and Justice.
A physician shall, in the provision of appropriate patient care, except in emergencies, be free
to choose whom to serve, with whom to associate, and the environment in which to provide
medical care.
A physician shall recognize a responsibility to participate in activities contributing to the
improvement of the community and the betterment of public health.
A physician shall support access to medical care for all people.
Adopted by the AMA's House of Delegates June 17, 2001
Medical care defined by Courts, Legislatures, Commissions, Media, Ethics Committees, and
others.
No longer does the doctor make decisions alone nor does the autonomous patient exercise
his/her rights without interference.
Clinical ethics: decisions are more process oriented than outcome oriented, requiring a
process of consensus building, no matter the outcome.

ETHICAL DECISIONS:
End-of-life Issues
• Palliative Care
• CPR decisions
• Euthanasia
• Withholding & withdrawing treatment
• Futile care

PRACTICAL PRINCIPLES FOR ETHICAL DECISION MAKING:

Identify source of authority for decision making.
Achieve effective communication with patient and families
Carry out early determination and ongoing review of patient's desire.
Clearly recognize patient's rights.
Carry out hospital policies.
Protect the nurse's own standards of care.
Palliative care: caring for a patient to relieve pain and make the dying process as peaceful as
it can be. Depending on patients' wishes, they are given food and hydration.
CPR Decisions: Ethical questions on CPR: in what situations, for how long?
Do not resuscitate(DNR): orders are commonly implemented in the critical care setting as a
prelude to end-of-life care.
Euthanasia: Euthanasia, a Greek word meaning "good death," is popularly known as "mercy
killing." Classified by Active euthanasia and Passive euthanasia
Withholding or withdrawal off life support: Withholding: never initiating a treatment
Withdrawing: to stop a treatment once started the treatment.
Best made after careful discussion (health care professional, patient and family)
Futile medical care: is the continued provision of medical care or treatment to a patient
when there is no reasonable hope of a cure or benefit.

LEGAL DECISIONS IN CRITICAL CARE UNITS:

Medical documentation, Use of restraints, Declaring Brain death, Passive Euthanasia, Organ
donation, Autopsy
Medical Documentation: medical documentation include Informed consentAdvanced
Directives, Incident Reports. The all documentation represents that, ‘if you didn’t document
it, you didn’t do it’.
Informed Consent
In order to be considered legally effective, consent to medical treatment must meet three
tests:
(1) voluntary
(2) adequately informed or knowing.
(3) given by an individual with adequate mental capacity and legal authority.
Incident reports
Document the occurrence of anything out of the ordinary that results in, or has the potential
result in, harm to a patient, employee or visitor.
The nurse responsible for a potentially or actually harmful incident or who witnesses an
injury is the one who fills out the incident form.
Other Important legal documents
Consultations & referral slips
Nurses record
Treatment and investigation record TPR chart, BP monitoring chart, IO chart/ Progress report
Operative notes
Discharge summary
Death certificate

Use of Restraints:
It is the intervention that limits a person's freedom to move specially needed for pediatric
patients. It may Physical or chemical and use only when all other methods have failed as a
last resort. Use least restrictive method possible to the babies.
Nurses' related factors influence the use of physical restraint in critical care units
It can be concluded that those older nurses and those with higher qualification and years of
experience have better performance than others.
Nurses' knowledge and performance are in need for improvement
Declaring Brain death:
Require a physician not involved in the patient treatment to document brain death and another
physician to confirm the findings. 3 essential findings in brain death are coma, absence of
brainstem reflexes, and apnea.

Passive euthanasia:
Passive euthanasia is legal in India. On 7 March 2011 the Supreme Court of India legalised
passive euthanasia by means of the withdrawal of life support to patients in a permanent
vegetative state.

Organ donation Decision:

The donation can be made by a provision in a will or by signing a card- like form.
Nurses may serve as witnesses for people consenting to donate organs.
Autopsy: An autopsy or postmortem examination is an examination of the body after death.
The law describes under what circumstances an autopsy must be performed, for example, all
Medico-Legal Cases should undergo autopsy.

PATIENT'S BILL OF RIGHTS:

1. Right to considerate & respectful care.
2. Right to information
3. Right to make decisions
4. Right to have advance directive
5. Right to privacy
6. Right to confidentiality
7. Right to review the records
8 Right to proper treatment and referral
9. Right to ask & be informed of the existing business relationship among hospital providers
or payers educational institutions, other health care
10. Right to consent to participate in research
11. Right to reasonable continuity of care
12. Right to be informed of hospital policies.

WHICH CASES ARE MEDICO LEGAL:

All cases of injuries.
All cases of burn.
Alleged cases of assault.
All cases of suspected or evident of poisoning or intoxication.
Case referred from court
Cases of suspected or evident criminal abortion
Cases of unconscious/comatose where its cause is not natural or not clear
Cases brought dead/dead on arrival/sudden unexpected death etc
Cases of suspected self inflicted injuries or attempted suicide

IMPORTANT LEGAL DOCUMENTS:

Specialist consultations & referral slips
Nurses record
Treatment record
TPR chart, BP monitoring chart, 10 chart/ Progress report
Operative notes, Anesthetists notes
Final diagnosis
Discharge summary & follow up notes/ death certificate

4 A's" and "4 R's":

A resource developed by the American Association of Critical-Care Nurses (AACN). The 4
A's are sequential steps in raising one's awareness and committing to action.
1. Ask - Reflect to become aware of your feelings of moral distress. Are you and/or team
members experiencing moral distress?
2. Affirm-Validate your feelings with others and make a commitment to address moral
distress.
[Link]-Assess the degree of your distress and your readiness to act.
4. Act-Make a personal and professional action plan. Carry it out and act to sustain the
change,
If you are uncertain about taking action, the 4 R's can help you to clarify
1. Relevance - In what ways and to who is the issue important?
2. Risks - What are the risks of taking action and of NOT taking action?
3. Rewards - What benefits can be obtained by acting and various courses of action?
4. Roadblocks - What are the barriers to taking action or a particular course of action?

LEGAL SAFEGUARDS FOR NURSES:

Informed consent
Contract
Collective bargaining
Competence practice
Licensure
Patient education
Executing physician's order
Documentation
Professional liability insurance
Good samaritan law
Adequate staffing
Patient's bill of rights

NURSING COUNCIL ACT 2052:

A person who carries on the nursing profession in contravention of Section 20 (Prohibition on
carrying on nursing profession: No person other than a registered nursing professional shall
be entitled to carry on the nursing profession, directly or indirectly) shall be punished with a
fine not exceeding Three Thousand Rupees or with imprisonment for a term not exceeding
Six months or with both.

CONSUMER PROTECTION ACT 2054:

A person who commits or cause to commit any Act in violation of Section 10 (To mislead
consumers by making false or misleading claim that the consumer goods or service, to
engage in unfair trade practices in such a manner as to make false or misleading publicity or
advertisements) shall be punished with imprisonment for a term not exceeding five years, or
with a fine not exceeding One Hundred Thousand Rupees or with both.
To produce, sell or supply any of the consumer go or services which may cause harm to the
health of consumers
1)If there is a threat to life, for a term not exceeding fourteen years, or with a fine not
exceeding Rs 500,000, or with both.
2) In case the strength of any organ of the body is likely to be reduced or lost, with
imprisonment for a term not exceeding ten years, or with a fine not exceeding Rs 500,000, or
with both.
3) In other circumstances, with imprisonment for a term not exceeding five years, or with a
fine not exceeding Rs 300,000, or with both.

"For the implementation of high quality of nursing practice in the world of latest medical and
technological advances, good knowledge of legal right is necessary."

ETHICAL ISSUES IN PEDIATRICS:

Refuse immunizations
A large number of parents refuse to vaccinate their children, despite evidence dispelling
myths and supporting immunization.
Refuse seek care
Parents have the responsibility and authority to make medical decisions on behalf of their
children. This includes the right to refuse or discontinue treatments, even those that may be
life-sustaining. However, parental decision- making should be guided by the best interests of
the child.
Genetic therapy
Gene therapy involves making changes to the body's set of basic instructions, it raises many
unique ethical concerns
Withhold therapy vs. Withdrawal of Treatment
A decision to withdraw or withhold treatment may seem like giving up. But when physicians,
patients and family members communicate effectively as a team, it can be very satisfying and
empowering.
Informed consent
The most important goal of informed consent is that the patient has an opportunity to be an
informed participant in her health care decisions.
Pediatric nurses are trained in child development health care and diseases of children. They
deal with infants all the way up to adolescent children. These types of nurses specialize in
examining both the physical and psychosocial well-being of a child.
The ethical issues pediatric nurses face can be quite challenging at times, as they must often
professionally solve conflicts involving a family's personal values. Pediatric Before a nurse
administers treatment, medication or other forms of health care, the nurse has the
responsibility of informing the patient and the family caring for the patient of the treatment.
The patient or the patient's parents must be fully aware of what is going on.
In some cases, a patient, parent or guardian must sign a consent form, depending on the type
of treatment the pediatric nurse is administering or providing. If the pediatric nurse does not
fully explain the form of health care, the patient could become ill as a result, which will bring
the issue of a lawsuit for the health care provider and the pediatric nurse.
Coping skills: If a child is recently diagnosed with a serious condition, it can be quite
overwhelming for both the child and family members. A pediatric nurse has the responsibility
of helping both the parents and child learn to cope with a serious illness.
Restraining a child
There are certain procedures that require pediatric nurses to restrain a child. In some
situations it's absolutely necessary in order to protect their safety
For example, if a child is in need of stitches but refuses to hold still, the child would need to
be retrained for the procedure.
Refusing treatment
The parent ultimately has the right to refuse treatment for their child, as children are minors.
Therefore, it can be quite challenging for a nurse to have to pull a child from life support or
not give a child certain treatments that may help them recover, when the nurse feels that it's
ethically right to do so.
Religious beliefs
Despite a pediatric nurse's spiritual or religious beliefs, she must comply with the family's
beliefs, not allowing her own feelings to personally get in the way.
Accepting reality
Losing a child can be the most difficult thing a family will ever go through. In some cases,
parents refuse to accept this, and want to perform more treatments.
However, a pediatric nurse must help family members understand when there is nothing else
that can be done in order to save the child.

ISSUES IN PEDIATRIC NURSING

Pediatric nurses are professional registered nurses who often assist in the care and treatment
of young children or babies. The young children and babies are sick, and some are terminally
ill and dying.
A pediatric nurse has to remain ethical and keep the best interest of the patient in mind at all
time to avoid legal issues.

HEALTH ISSUES
A pediatric nurse is always put in dangerous situations, which is an issue for the nurse.
Pediatric nurses are exposed to health hazards, such as infectious disease because of the
places he works, and the direct contact the pediatric nurse has with patients.
Pediatric nurses run the risk of being injured by sharp object such as needles and blades.
A pediatric nurse can also face the issues of musculoskeletal problems and other back pain
problems due to carrying children and babies.
PATIENT ADVOCATE
A pediatric nurse has the duty of remaining an advocate for the patient. If the patient's activity
after or during treatment changes.
A pediatric nurse has the responsibility of alerting physician of these changes immediately. If
the patient's physician is not on call or working, then the pediatric nurse has the responsibility
to notify a working physician who can provide proper care
CONFIDENTIALITY
All information of the patient a pediatric nurse is caring or treating must remain confidential.
The pediatric nurse may not share the patient's condition with anyone outside of the parents,
or authorized family, guardian or friends of the patient.
Violating the patient's privacy is a violation of the nursing ethics. A pediatric nurse is made to
follow, and a lawsuit can result because of this violation. Along with a lawsuit, the pediatric
nurse can run the risk of losing his job and nursing license.
BEST INTEREST OF PATIENT
Pediatric nurses must have the ability to treat and comfort patients who are dying. A legal
issue that can arise with a pediatric nurse is not honoring the wishes of the patient or the
patient's parents and guardians.
Some pediatric nurses become emotionally attached to patients, and take matters into their
own hands.
The pediatric nurse has a legal obligation to respect the wishes of the patient, and do what is
in the patient's best interest.
Violating orders can lead to job and license loss of the pediatric nurse.
ETHICAL DILEMMAS EXPERIENCED BY NURSING WORKING IN CRITICAL
CARE UNITS:
Identified "end-of-life decisions, Patient care issues and human rights issues" as the emerging
ethical issues. In resolving the dilemmas most of the participants indicated that they would
report the issues to the physician.
An ethical dilemma is one in which a person has to choose between two options, both of
which are morally correct but in conflict.
The nurse must make a choice between two alternatives that are equally unsatisfactory. They
both deal with questions of right and wrong.
Such dilemmas may occur as a result of differences in cultural or religious beliefs.
Examples of nursing ethical dilemmas
INAPPROPRIATE MEDICATION ORDERS
• Giving wrong medication dosages or medication for the wrong illness is unsafe for patients
and may lead to death.
• Nurses can find themselves in an ethical dilemma when they have to challenge a medication
order written by a physician.
UNRESPONSIVE PHYSICIANS
• Nurses often have to call on physicians in situations beyond their scope of practice such as
medical emergencies.
• The nurse finds herself in an ethical dilemma if the physician does not respond and her
patient's condition goes from bad to worse.
INAPPROPRIATE TASKS
• Nurses float from department to department in the course of their career.
• When a nurse finds herself in an unfamiliar department and is asked to provide care she is
inadequately trained for, she may have to refuse to provide care to avoid making the patient
unsafe.
LIFE THREATENING PATIENT DECISIONS
Patients sometimes make decisions that are unsafe, such as refusing treatment for a baby,
medication or lifesaving procedures.
The nurse finds herself in an ethical dilemma because not giving the needed treatment goes
against beneficence and giving it ignores patient autonomy.
SOLVE AN ETHICAL DILEMMA
Consider your own motives and try to detach them from your decision. If your ethical
dilemma is whether to tell your friend's husband that she's cheating, your instinct might be to
keep quiet rather than potentially lose your friendship.
Take your own feelings out of the equation and focus on consequences to the involved
parties.
Consider your moral code of conduct. If you're pondering ethical issues, you must have a
strong sense of right and wrong.
Ask your conscience what the right thing to do is. See if that makes the dilemma easier to
solve.
PEDIATRIC CODE OF ETHICS
Pediatricians are physicians who specialize in the care of infants and children. They are
respected and trusted members in the community.
The American Medical Association (AMA) developed a code of medical ethics that the
organization says contains "standards of conduct that define honorable behavior" for
physicians.
PATIENT CARE
According to the AMA Principles of Medical Ethics, physicians should be dedicated to
providing competent medical care and take care to respect patients' dignity and rights.
They should also be responsible for a patient who is under their care, and support medical
access for everyone.
PATIENT CONFIDENTIALITY
Physicians should respect the rights of their colleagues and other health professionals, as
well as protect patient confidentiality and privacy.
COMMUNITY INVOLVEMENT
The AMA suggests that physicians have a responsibility to get involved in their community
by participating in activities that improve public health.
RESEARCH
Physicians are required to study and advance their medical knowledge.
They should make relevant medical information available for patients, other physicians and
the public.
THE LAW
The Principles of Medical Ethics also state that physicians should respect the law when
providing patient care, but also seek to change the law if it is in the best interest of the patient

CULTURAL ISSUES IN PEDIATRICS

Cultural beliefs and traditions affect family members to perceive health & illness. Each
culture has its own beliefs and values and that is based on generation to generation.
SOCIOECONOMIC FACTORS
A higher percentage of low socioeconomic group children suffer from many health problems.
Children of lower classes are unlikely to be immunized properly. Nurse must enquire about
immunization and provide nutritional information.
POVERTY
Improvised families suffer from poor nutrition.
Most significant health problem associated with poverty is high infant mortality rate.
Due to lack of money, people may consult folk practitioners.
Inadequate diet leads to nutritional deficiencies (like anemia) and also growth retardation in
children.
Poor sanitation and overcrowding leading to illness.
MIGRANT FAMILIES
Their children mostly suffer from dental caries, upper respiratory tract infection, tuberculosis
and growth and development delay
Even if medical care is provided for migrants, follow-up is difficult.
CUSTOMS AND FOLKWAY ON HEALTH
The more the nurses know about the values, beliefs and customs and other ethinic groups,
they are better able to meet the needs of these families.
For example: some culture view chronic illness or disability as affecting only particular
aspects of child's life and the whole child is viewed as normal.
In some cultures, gender may influence a family's perception of implications of illness or
disability.
For example: in Arabic and Asian cultures, male child is having higher esteem.
Different diseases or signs and symptoms of illness is also influenced by culture
For example: diarrhea is considered as cleaning of the body that is essential for health
maintenance and illness prevention.
FOOD CUSTOMS
Food customs and symbolism are an integral part of various cultural, ethical and religious
groups
Special holidays, ceremonies, birthdays and deaths are often marked by a special food items
There are many dietary restrictions in few cultures causing malnutrition in children For
example: seven- day Adventists vegetarian diet.

CONCLUSIONS:
The term 'ethic' comes from the Greek word: ethikos which means 'moral, character'
The branch of philosophy concerned with the distinction between right and wrong based on a
body of knowledge, not based only on opinions. As a pediatric nurse all needs to keep in
mind the ethics and laws related to the pediatric nursing and ethical consideration in every
aspect to responsibilities and duties.
BIBLIOGRAPHY:

[Link] Richerde. Nelson text book of pediatrics 16 edition. Harcourt india Pp -5-9, 11-
13.
2. Parthasarathy A. Text book of pediatrics. Jaypee publisher. 8th edition. Pp-160
3. Marlow R. Dorothy Text book of pediatric nursing. Elsevier publisher. Sixth edition. Pp-
383-384
[Link] A text book of child health nurse
Jaypee publishers. 1st edition. Pp-31-32
5. WEBSITE
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[Link] 's rights in India
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[Link]
Cultural and Ethical Issues Concerning Research on American Indian Youth