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KEY POINTS

KEY POINTS

  1. The four principles of biomedical ethics—beneficence, nonmaleficence, autonomy, and justice can provide a rubric through which clinicians can identify ethical dilemmas in clinical practice.

  2. Informed consent is a process of mutual respect between a clinician and a patient that involves (a) ensuring that the patient has the capacity to make the specific medical decision; (b) the skillful disclosure of relevant information to the patient; and (c) ensuring that the patient’s expressed choices are voluntary.

  3. Advance care planning is a process by which patients, with facilitation by a trained professional, clarifies their current health state, goals, and objectives.

  4. A living will is any document where the patient anticipates a specific set of medical circumstances and requests or refuses specific types of treatment under each of these medical circumstances.

  5. A health care proxy form allows a patient to name a surrogate decision-maker in the event they become unable to make medical decisions for themselves.

  6. In shared decision-making, clinicians are considered the experts on prognosis/treatment options, whereas the patient/family is considered the expert on the patient’s values.

  7. Palliative care is a multidisciplinary, patient-centered approach to care that focuses on (a) assessing and treating symptoms; (b) providing psychological and spiritual support to patients and families; (c) facilitating treatments that are better aligned with patients’ values by ensuring skillful, proactive, and compassionate communication between the clinical team and the patients/families.

  8. Most patients die in the ICU after the withdrawal or withholding of some life-sustaining treatments.

  9. The withdrawal of life-sustaining treatments should be considered a clinical procedure that requires expertise, careful preparation, appropriate documentation, and ongoing evaluation.

INTRODUCTION

With the inevitable advancement in technological innovation and the aging of the population, more patients with chronic medical problems will face complex medical decisions in intensive care units (ICUs). Although most ICU patients survive, many deaths occur in or directly following an ICU stay.1 Dying in the ICU has become a negotiated process, most often requiring some limitation of life-sustaining treatments.2 ICU survivors struggle with physical and psychological symptoms, and functional and cognitive impairments, and their families struggle with caregiver strain in the face of an increasingly fragmented health care system.3 Patients come to the ICU with diverse expectations and values but are often too incapacitated to fully express them. Families, in the face of their own grief and bereavement, are asked to represent the patient, often weighing the possibility of impaired survival or death with the hope of recovery. All of these factors combine together to make the ICU a clinical arena rife with potential for conflict, making it increasingly important for the ICU clinician to be able to integrate the principles of bioethics and palliative care into the clinical care they provide their patients in the ICU.

This chapter will first discuss the key ethical principles and theories that provide a framework for medical decision-making in the ICU. Second, it will review ...

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