It turns out that my medical school was correct in requiring midweek electives during the first and second years. Two particularly memorable classes were Bioethics and Death, Dying, and Bereavement. Although I didn't realize it at the time, I learned things then that I use daily in the intensive care unit (ICU) now—almost 30 years later.
Although articulating the role of bioethics in bedside care may seem difficult, the 5th International Consensus Conference in Critical Care held in 2003 in Brussels provides this perspective:
The overriding goal for all involved parties should be to act in the patient's best interests. The decision to limit life-sustaining treatments in the ICU should be based on widely held ethical principles such as autonomy (the right of patients to make their own health-care decisions), beneficence (health care should benefit the patient), nonmaleficence (health care should do no harm), and distributive justice (resources should be used in a fair and equitable manner). Reasons for withholding or withdrawing therapy may therefore include patient refusal, the unlikelihood that a patient will benefit from a therapy because of a poor prognosis, or the failure of a therapy to improve a patient's condition after a reasonable trial. Application of these principles may, however, be complicated. There may be a conflict, such as when the family of a terminally ill patient demands a costly therapy that consumes scarce resources, and not all individuals or societies fully accept these ethical principles, so the decision-making may vary.1
As one can see from this position statement, almost all decisions regarding the care of critically ill patients involve bioethics. The bioethical context of care in the ICU setting is accentuated by the following factors:
Patients are at increased risk of dying.
Many patients are unable to participate directly in their own care.
Shared decisionmaking necessitates effective communication among the patient, family, and medical providers.
Technologically advanced care is typically expensive, and its availability may be limited.
When faced with such value-laden conflicts in caring for patients, ICU clinicians should consider a bioethics consultation. “Ethics consultation is a service provided…to address the ethical issues involved in a specific clinical case. Its central purpose is to improve the process and outcomes of patient care by helping to identify, analyze, and resolve ethical problems.”2 These consultations typically focus on questions regarding the patient's decision-making capacity, conflicts between staff and families, challenges in end-of-life care, and appropriateness of care. Failure to attain alignment of goals and expectations among the patient, family, and healthcare team may lead to a question of medical futility or even moral distress. In these situations, consultation with the bioethics committee may allow conflict resolution.
In addition to assisting in the care of individual patients, bioethics expertise is necessary to establish best practices for ethical and end-of-life care in the ICU. Specific direction includes the development of institutional policies such as ICU admission and transfer, daily multidisciplinary rounds, measures to facilitate provider communication with families, and withholding or withdrawing of life-sustaining therapy.3 Bioethics consultation is intended to accomplish the following:
Individualized care—promote ethical resolution of a specific case.
Communication—encourage respectful communication among involved parties.
Education—teach those involved in the case how to work through future ethical uncertainties on their own.
Policy development— help the organization recognize issues that require institutional attention.
In summary, bioethics consultation should be available to guide physicians in caring for individuals as well as larger populations. Although formal bioethics education may be an elective experience, the challenges unique to the ICU make understanding these concepts essential to providing high quality care to critically ill patients.
- Academic Division of Ochsner Clinic Foundation
