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LEGAL AND ETHICAL ISSUES
IN
CRITICAL CARE
NURSING
LOPAMUDRA MAHANTY
M.Sc.NURSING 2ND YEAR
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 INTRODUCTION

Critical care has come to be associated with

high-tech, aggressive & often risk-filled medical
care. The critical care nurse are often confronted
with ethical & legal dilemmas related to various
ethical principles.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 3

 TERMS AND MEANINGS

ETHICS :-
Moral principles that govern a person's behaviour or
the conducting of an activity.
NURSING ETHICS:-
The values and ethical principles governing nursing
practice, conduct, and relationships. It is intended to
provide definite standards of practice and conduct that
are essential to the ethical discharge of the nurse's
responsibility.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 4

 TERMS AND MEANINGS
ETHICAL ISSUE
• A problem or situation that requires a person or
organization to choose between alternatives that must
be evaluated as right (ethical) or wrong (unethical).
LEGAL ISSUE
• Legal issue or issue of law is a legal question which
requires a court's decision. It can also refer to a point on
which the evidence is undisputed, the outcome of which
depends on the court's interpretation of the law.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 5

 ETHICAL PRINCIPLES

1. Autonomy
Autonomic choices and autonomous actions of
an individual.
2. Beneficence
Take positive actions to help others and follow
through on the desire to do good.
3. Nonmaleficence
Avoid causing suffering or injury to patients.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 6

 Cont…..
4. Justice
All clients must be treated fairly and equally
5. Veracity
Honest and full disclosure to the patient, abstain from
mis- representation, and report known lapses of the
standards of care to the proper agencies
6. Fidelity
It includes dedication, loyalty, truthfulness, advocacy
and fairness to patients

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LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN
 LEGAL AND ETHICAL ISSUES
IN CRITICAL CARE NURSING
1 Informed consent

2 Valuables in critical care unit

3 Medico legal case (MLC)

4 Medical documentation

5 Use of restraints

6 Decision regarding life supporting

treatments
LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 8
 1. INFORMED CONSENT

“It implies to permission by the patient to perform an

act on his body either for diagnosis or therapeutic
procedure.” The informed consent is based on the
principles of autonomy.

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LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN
 Cont…..

3 elements of consent
voluntariness
Information
Decisional capacity

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 10

 CONSIDERING POINTS UNDER CONSENT

• Should be given by a person of

- Sound mind
- Above the age of 18 years
- Free from pain & depression
• Must be given voluntarily.
• If patient is not mentally capable it should be
obtained from surrogate or legal next of kin.
• Requires the disclosure of basic information
necessary for decision making

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 11

 2. VALUABLES IN CRTICAL CARE UNIT

 Immediately handing over the valuables (gold,

jewellery, cash) to a responsible relative.

 Listing of articles in duplicate, signed by the person

receiving and the witness.

 The articles with the list are kept in safe custody until
it is handed over to the next of kin or the patient
himself when he becomes well.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 12

 3. MEDICO LEGAL CASE

“A medico legal case is any case where

the discipline of medicine comes to
help the legal fraternity in its discharge
of duties.”

Health care professionals have to be

very cautious in dealing with the medico
legal cases.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 13

 MLC CASES

All cases of -
Injuries
 Burn
Assault
Poisoning or intoxication
Cases referred from court
Criminal abortion
Unconscious/comatose where cause is not natural
Brought dead, sudden unexpected death
Attempted suicide LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 14
 Cont….

Important considerations in MLC

Notification to police

Collection & preservation of samples

 Recording of dying declaration

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 15

 4. MEDICAL DOCUMENTATION

The proper medical documentation is legal necessity.

A good record should be ( 5 Cs)

 Correct
 Clear
 Comprehensive
 Chronological
 Contemporaneous

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LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN
 Cont…..
LEGAL DOCUMENTS
 Specialist consultations
MEDICO-LEGAL DOCUMENTS
 Referral slips  Death certificate
 Nurses record  Medico legal reports
 Treatment record  Medico legal investigation
 TPR chart reports
 IO chart
 operative notes
 Anesthetists notes
 Progress report
 discharge summary
 Follow up notes
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LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN
 Cont…

The document once prepared has to be preserved for

specified period of time (3 years) from the date of
commencement of treatment.

If any request is made for medical records either by

patient or legal authorities, the documents shall be
issued within period of 72 hours.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 18

 6. RESTRAINTS

• Restraints are intervention that limits a

person’s freedom to move.
• Physical restraint can lead to:
- Skin trauma
- Muscular atrophy
- Nosochomial infection
- Limb injury
• Restraint consent to be taken before
application.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 19

 6. DCISION REGARDING LIFE
SUSTAINING TRATMENT

Indications:
1. When resuscitative measures are futile.

2. When patient had wanted DNR by advanced

directives (written/verbal) or the surrogate decides
not to sustain.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 20

 Cont…..

It includes
1. CPR decisions
2. Withholding or withdrawing of treatment

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 21

 1. CARDIO PULMONARY
RESUSCITATION DECISIONS
1. CPR CESSATION 2. DO NOT RESUCITATE (DNR)
CPR should cease if the physician ORDER
determines the efforts to be Written instructions from a
futile or hopeless. physician telling health care
Duration: providers not to perform CPR.
30 mins (adult/child)
15 mins (newborn)

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN

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 2. WITHHOLDING OR
WITHDRAWING OF LIFE SUPPORT

INDICATIONS
• Patient having GCS < 5
• Absence of pupil & motor response
3 days after arrest.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 23

 POINTS TO BE CONSIDERED

 Should be made after careful discussions between

the health care professional & the patient (or
surrogate).

 Provide consistent, honest information.

 Ensure that the patient/surrogate understands the

information.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 24

 LIABILITY RISK ISSUES IN CRITICAL CARE NURSING

Risk managements overall goal is to reduce or prevent

any type of risk to the health care facility.  

Nurses can be found legally liable, or responsible for

mistakes made.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 25

 COMMON CAUSES OF LIABILITY

 Physical harm due to restraints

 Equipment malfunction
 Errors in administration of medication and
treatment,
 Failure to observe and report changes in
patient’s condition,
 Burns caused by application of heat
 Accidental disconnection from life saving
machines.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN

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 AREAS OF LIABILITY RISK ISSUES

Medication administration

Standard of care
AREAS
OF
LIABILITY
DNR, with-holding withdrawing life

Witnessing
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LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN
 1. ADMINISTRATION OF
MEDICATION
Standing orders:-
Standing orders should be formulated in consultation
with management , medical director and nurse manager,
which should be made available to the staff and followed
strictly.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 28

 2. STANDARD OF CARE

Nurse manager has the responsibility to plan staffing in

such a way as to cover all shifts with the available
experienced staff along with the inexperienced staff
thereby standard of care need not be compromised.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 29

 3. DNR, WIHHOLDING,
WITHDRAWING LIFE

Support orders:-
Medical orders for not resuscitating withholding or
withdrawing life support should be written down in
the patient’s records by an authorized physician
working in the unit.

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN 30

 4. WITNESSING

When the nurse is asked to be witness, she should :

- Be prepared to answer any questions to
describe the standard and to define nursing
and the nurse’s role.

- Have belief on self and explain the reason of

action.

- Limit the answer to yes, no or i don’t

know or I don’t recall

- Avoid vague and blanket statement. 31

LOPAMUDRA MAHANTY, COLLEGE OF NURSING, MSN
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