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Chapter 07:
Ethical Issues in Critical Care
Nursing
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
ANA’s Code of Ethics for Nurses
See Box 7-1.
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Bioethical Principles
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Risk-Benefit Analysis
• Identify the benefits and risks involved.
• Do the risks outweigh the potential benefits?
• What are the overall goals for caring for the patient?
• What alternatives instead of the proposed care exist?
• Is the comfort of the patient compromised?
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The Five Steps of Ethical Decision Making
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Resources Available to the Nurse to
Resolve Ethical Dilemmas
• Institutional ethics committee
• Nursing ethics committee
• Pastoral care
• Peer support
• Quality assurance
• Professional organizations
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Case Study 1
A disaster has brought 35 new patients to the hospital. Many of
the new patients are being treated and kept in the cafeteria.
You are the charge nurse and need to decide what to do with
the seven ICU patients that you have. There are two beds
available on the step-down unit and there is one bed on the
medical-surgical unit.
Using the principles of ethics, decide who will go to the stepdown beds and who will go to the medical-surgical bed so that
you can take three critically ill patients who qualify using the
triage guidelines. All seven patients in the ICU are equally
unstable. How could you ethically make the decision? What are
your options?
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Case Study 2
Two clients are on a transplant waiting list, and both
qualify for the one heart that is available. Which of the
following clients would you choose, using ethics to guide
you? Give your rationale.
Client 1 is a 34-year-old single mother of one child who
had a heart transplant 6 months ago; the heart
transplant is failing and she needs another. She is an
active IV drug abuser who has not been successful with
drug rehabilitation.
Client 2 is a 55-year-old woman who was placed on the list
3 weeks ago. She has two teenage children to raise.
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Question
Which of the following is the ethical approach that
considers the emotions and character traits of a
relationship between people as essential when
determining the right thing to do?
A. Utilitarianism
B. Deontological
C. Ethics of care
D. Virtue ethics
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Answer
C. Ethics of care
Rationale: Ethics of care emphasizes the characteristics of
a caring relationship as essential in determining the
right thing to do. According to utilitarianism, the right
action is the one that provides the greatest benefit with
the least burden to all parties involved. The
deontological approach considers conformity to the
action of moral rules. According to virtual ethics, what
matters is what agents do and whether their actions
reflect their virtues.
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Question
Which of the following statements about the ethics
committee at an institution is correct?
A. The committee is made up entirely of physicians.
B. The Joint Commission requires an institution to have
guidelines pertaining to decisions about end-of-life care.
C. A physician must write an order before the ethics
committee becomes involved in a situation.
D. The family must give permission before the ethics
committee is consulted.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. The Joint Commission requires an institution to have
guidelines pertaining to decisions about end-of-life care.
Rationale: The Joint Commission requires an institution to
establish guidelines pertaining to end-of-life care,
including the process to address ethical situations,
informed consent, and surrogate decision making. The
ethics committee is made up of doctors, nurses, social
workers, clergy, and laypersons from the community.
No order is needed to consult the ethics committee. The
family does not have to grant permission for the ethics
committee to be consulted, but the family should be
made aware.
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Question
The American Association of Critical Care Nurses directly
addresses moral distress in the critical care work
environment through:
A. The healthy work environment
B. Crucial conversations
C. Ask, affirm, assess, act
D. Code of Ethics for Nurses
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
C. Ask, Affirm, Assess, Act.
Rationale: The AACN proposes the use of the four A’s (ask,
affirm, assess, and act) to help the nurse to deal with
moral distress. The healthy work environment initiative
involves open communication among health care
professionals and the administration. Crucial
conversations help the nurse to be assertive and to be
able to hold needed conversations with others, keeping
the interest of the patient as a top priority. The ANA’s
Code of Ethics provides guidelines for ethical decision
making.
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