Ethical Dilemmas in Critical Care
6
Ethical Principles
Autonomy beneficence non-maleficence justice fidelity veracity
1
Primary Obligation
To the PATIENT not the family
2
Standards
Substituted judgment and best interest
Six Ethical Principles
The nurse's primary obligation is to the PATIENT, not the family or the physician. When ethical principles conflict, the nurse must advocate for the patient's known wishes and best interests.
Autonomy Respect the patient's right to make their own decisions
Beneficence Act in the patient's best interest
Non-maleficence Do no harm
Justice Fair and equitable distribution of resources
Fidelity Keep promises and commitments
Veracity Tell the truth
Advance Directives and DNR
Advance directives are legal documents that express the patient's wishes regarding future medical care. A DNR order specifically addresses cardiopulmonary resuscitation only. It does NOT mean do not treat. The patient continues to receive full active care including medications, monitoring, and interventions. Only CPR is withheld in the event of arrest.
Key Values to Memorize
Patient > family wishes
Advance directive > surrogate
Withdraw = withhold
DNR ≠ do not treat
Substituted judgment first
Autonomy = right to refuse
ethics questions make up 20% of the CCRN exam
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Withdrawing and withholding treatment are ethically equivalent
This is a critical concept the exam tests repeatedly. There is no ethical distinction between stopping a ventilator and never starting it. Both represent a decision to not provide a treatment. Many nurses feel that withdrawing is "harder" than withholding, but ethically and legally they are the same. The patient's wishes and best interests guide both decisions.
Advance directive trumps family wishes
If a patient has a valid advance directive stating they do not want mechanical ventilation, the family cannot override this. The patient's autonomous decision, made while competent, takes precedence. The family's role is to convey the patient's wishes, not to substitute their own.
Autonomy means the right to refuse even life-saving treatment
A competent patient has the absolute right to refuse any treatment, including treatments that would save their life. This can be profoundly difficult for nurses, but respecting autonomy means honoring the patient's decision even when you disagree. Document the conversation and ensure informed refusal.
DNR does NOT mean do not treat
A DNR order means do not perform cardiopulmonary resuscitation if the patient arrests. It does NOT mean withhold antibiotics, fluids, pain management, or any other active treatment. The patient is still receiving full care. The DNR only addresses the specific scenario of cardiac or respiratory arrest.
Patient First
Your primary obligation is to the PATIENT, not the family, not the physician, not the institution. When in doubt, advocate for the patient.
Advance Directive Rule
Valid advance directive > family preferences. The patient already made their choice. Your job is to honor it.
Critical care creates storms. The family wants everything done. The patient wrote a directive saying no machines. The physician recommends continued treatment. Everyone is emotional. The situation is unclear and the stakes are life and death.
The six principles are your compass. Autonomy says honor the patient's choices. Beneficence says act in their best interest. Non-maleficence says do no harm. Justice says be fair. Fidelity says keep promises. Veracity says tell the truth. When the storm rages, check your compass.
When the patient cannot speak for themselves, two standards guide surrogates. Substituted judgment asks "what would the patient want?" Best interest asks "what would a reasonable person want in this situation?" Substituted judgment is preferred because it honors the patient's values.
No matter how complex the situation, your true north is always the patient. Not the family's preferences. Not the physician's recommendation. Not institutional policy. The patient. Every ethical decision flows from this starting point.
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