Medical Ethics in ICU

Quick Answer

Medical ethics in intensive care provides a framework for navigating complex decisions involving critically ill patients who often lack decision-making capacity. The four foundational principles—autonomy (respect for patient self-determination), beneficence (acting in the patient's best interest), non-maleficence (avoiding harm), and justice (fair distribution of resources)—guide clinical practice but may conflict, requiring careful ethical analysis. Key concepts include informed consent (voluntary, informed, competent decision-making), capacity assessment (understanding, appreciation, reasoning, communication), surrogate decision-making (substitute judgment standard vs best interests standard), advance directives (living wills, enduring powers of attorney), medical futility (quantitative vs qualitative vs inappropriate treatment), end-of-life ethics (withholding vs withdrawal, double effect, proportionality), resource allocation (triage, distributive justice), and conflict of interest (pharmaceutical industry, financial relationships). Legal frameworks vary by jurisdiction but generally recognize patient autonomy, advance directive validity, and substitute decision-maker authority. Cultural considerations—particularly for Indigenous Australians, Māori, and CALD populations—require culturally sensitive approaches that respect family decision-making structures, spiritual beliefs, and end-of-life traditions.

CICM Exam Focus

Written Exam High-Yield Topics:

Four principles of biomedical ethics: autonomy, beneficence, non-maleficence, justice
Beauchamp and Childress framework: principlism approach to ethical analysis
Capacity assessment: understanding, appreciation, reasoning, communication
Informed consent elements: disclosure, voluntariness, competence, understanding
Medical futility: quantitative vs qualitative vs inappropriate treatment
Advance directives: living wills, enduring powers of attorney, limitations
Surrogate decision-making: substituted judgment vs best interests standard
End-of-life ethics: withholding vs withdrawal, double effect, proportionality
Resource allocation: triage principles, distributive justice, pandemic ethics

Viva Voce Themes:

Ethical case analysis: applying principles to clinical scenarios
Capacity assessment: evaluating competence in critical illness
Informed consent in emergencies: implied consent, surrogate consent
Conflict resolution: family disagreements, unilateral decisions, ethics consultation
Advance directive interpretation: validity, relevance, conflict with clinical judgment
Medical futility disputes: consensus-building, ethics committee involvement
Resource allocation: triage decisions, ICU bed allocation, crisis standards of care
Professional boundaries: conflicts of interest, dual relationships, industry relationships

Key Points

Four principles of biomedical ethics (Beauchamp and Childress): autonomy (self-determination), beneficence (act for benefit), non-maleficence (do no harm), justice (fair distribution)
Principlism: framework for ethical analysis that balances these potentially conflicting principles
Informed consent: requires disclosure (relevant information), comprehension (understanding), voluntariness (no coercion), competence (decision-making capacity)
Capacity assessment: four domains—understanding (information), appreciation (impact on self), reasoning (weighing options), communication (expressing choice)
Advance directives: living wills (treatment preferences) and enduring powers of attorney (appointed decision-maker); validity varies by jurisdiction
Surrogate decision-making: substituted judgment standard (what patient would want) takes precedence over best interests standard (what surrogate thinks is best)
Medical futility: quantitative (physiological impossibility, below 1% survival) vs qualitative (unacceptable quality of life) vs inappropriate treatment (disproportionate burden)
Inappropriate treatment: preferred contemporary term; emphasizes that treatment may be medically possible but ethically unjustifiable
End-of-life ethics: withholding vs withdrawal (ethically equivalent), double effect (primary intent is symptom relief), proportionality (burden proportional to benefit)
Resource allocation: distributive justice frameworks (utilitarianism, egalitarianism, prioritarianism), triage principles (most likely to benefit, life-years, instrumental value)
Conflict of interest: situations where professional judgment may be compromised by secondary interests (pharmaceutical industry, financial relationships, research participation)
Ethics consultation: multidisciplinary ethics committees provide structured analysis of complex cases
Legal frameworks: vary by jurisdiction (Australian states/territories, New Zealand) but generally recognize advance directives, substitute decision-maker authority, and patient rights
Cultural considerations: Indigenous Australians (family decision-making, Sorry Business, passing on Country), Māori (whānau involvement, kaumātua, tikanga), CALD populations
Communication: SPIKES protocol for breaking bad news, structured family meetings, conflict resolution strategies

Clinical Overview

Ethical Principles and Frameworks

Principlism (Beauchamp and Childress):

Four foundational principles provide a framework for ethical decision-making in medicine
Autonomy: respect for patient self-determination and the right to make informed decisions about one's care
- "Grounded in Kantian ethics: persons are ends in themselves, not merely means"
- Requires capacity assessment, information disclosure, and absence of coercion
- Challenging in ICU where patients often lack capacity due to critical illness
Beneficence: obligation to act in the patient's best interest and promote their well-being
- Historical foundation: Hippocratic Oath, "benefit and do no harm"
- Requires careful consideration of what constitutes "best interest" for an individual patient
- May conflict with autonomy when patients choose treatments clinicians believe are not beneficial
Non-maleficence: obligation to avoid causing harm; "first, do no harm"
- Balancing benefits against risks is central to medical practice
- Particularly relevant in ICU where invasive interventions carry significant risks
- Primum non nocere may conflict with beneficence when beneficial treatments have unavoidable harms
Justice: fair distribution of benefits, burdens, and resources
- "Distributive justice: fair allocation of scarce resources (ICU beds, organs, ventilators)"
- "Procedural justice: fair processes for decision-making (transparent, consistent, inclusive)"
- "Social justice: addressing health inequities and determinants of health"

Application of Principles:

Principles often conflict: e.g., patient autonomy (request for futile treatment) vs beneficence/non-maleficence (avoiding harm) vs justice (resource allocation)
No hierarchy among principles; requires contextual balancing and ethical reasoning
Beauchamp and Childress' specification method: principles are specified to particular contexts to resolve conflicts
Reflective equilibrium: seek coherence between moral judgments and principles

Alternative Ethical Frameworks:

Deontological ethics: duty-based (Kant); actions are right or wrong based on adherence to rules/moral duties
Utilitarianism: consequentialist; actions judged by outcomes (maximizing overall good)
Virtue ethics: focus on character and professional virtues (compassion, integrity, courage)
Care ethics: emphasis on relationships, empathy, and responsiveness to needs
Casuistry: case-based reasoning; comparison with paradigmatic cases to reach ethical judgments

ICU-Specific Ethical Challenges:

Patients often lack decision-making capacity due to critical illness, sedation, or delirium
Time-sensitive decisions requiring rapid assessment and intervention
Invasive life-sustaining therapies with significant burdens and uncertain benefits
Family stress and conflict affecting decision-making
Resource constraints requiring allocation decisions
Professional and institutional interests that may conflict with patient interests

Definition and Purpose:

Informed consent is the process by which a competent patient voluntarily agrees to a medical intervention after receiving adequate information about its nature, risks, benefits, and alternatives
Fundamental ethical requirement for respecting patient autonomy and promoting shared decision-making
Legal requirement in most jurisdictions (civil battery if treatment without consent)
Therapeutic privilege (withholding information for patient's "benefit") is ethically and legally problematic

Elements of Valid Informed Consent:

Disclosure: Patient receives relevant information about the proposed intervention
- Nature of the procedure or treatment
- Risks and benefits (common, serious, and rare but serious risks)
- Alternatives (including no treatment)
- Uncertainties and limitations of medical knowledge
- Clinician's recommendations and reasoning
- Reasonable person standard: what a reasonable person would want to know
Comprehension: Patient understands the information provided
- Requires communication at appropriate level (language, health literacy)
- Teach-back method: patient explains back in their own words
- Address questions and concerns
- Use of visual aids, diagrams, interpreters as needed
Voluntariness: Decision is free from coercion or undue influence
- Absence of threats, manipulation, or exploitation
- Time pressure (emergencies) may impair voluntariness
- Family or institutional pressure may compromise voluntariness
Competence/Capacity: Patient has decision-making capacity
- Legal standard vs clinical assessment
- Capacity is decision-specific and time-specific
- Capacity assessment is clinical judgment, not legal determination

Capacity Assessment:

Definition: Ability to understand, appreciate, reason about, and communicate a decision
Four domains (Grisso and Appelbaum):
1. Understanding: comprehension of relevant information
  - Diagnosis and prognosis
  - Proposed treatment and alternatives
  - Risks, benefits, and uncertainties
2. Appreciation: recognition of how information applies to self
  - How illness affects patient's life and values
  - Personal implications of treatment decisions
3. Reasoning: weighing options to reach decision
  - Rational processing of information
  - Logical connection between values and decision
  - Consideration of consequences
4. Communication: ability to express choice clearly and consistently
  - Stable decision over time
  - Can articulate reasons
Capacity is decision-specific:
- Patient may have capacity for some decisions but not others
- Simple vs complex decisions require different cognitive abilities
- Capacity may fluctuate with illness, sedation, delirium, or metabolic derangements
Capacity vs competence:
- "Capacity: clinical assessment by treating physician"
- "Competence: legal determination by court"
- In practice, capacity assessments by clinicians are typically accepted
Assessment tools:
- Structured capacity assessment instruments (MacArthur Competence Assessment Tool)
- Informal clinical assessment (conversation, questioning)
- No single test; requires clinical judgment
Special considerations in ICU:
- "Delirium: very common in ICU, often impairs capacity"
- "Sedation: impairs understanding and reasoning"
- "Hypoxia, metabolic derangements: reversible causes of impaired capacity"
- "Time-sensitive emergencies: capacity may be temporarily impaired but urgent intervention required"
- "Chronic psychiatric conditions: may not impair capacity if stable"

Implied Consent:

Situations where explicit consent is impractical but patient would presumably agree
Emergency interventions: patient lacks capacity, urgent treatment required to prevent death or serious harm
Routine aspects of care within broader consent (e.g., blood tests after admission consent)
Must be truly necessary, consistent with patient values, and proportionate to risk

Surrogate Consent:

When patient lacks capacity, surrogate decision-maker provides consent
Surrogate should base decision on patient's known wishes (substituted judgment) or best interests
Legal frameworks define hierarchy of substitute decision-makers (varies by jurisdiction)

Documentation:

Consent discussions should be documented in medical record
Include: information provided, patient questions, patient understanding, decision made
Specific consent forms for high-risk procedures (surgery, ICU admission)

Challenges in ICU:

Patients often lack capacity due to critical illness or sedation
Family members may disagree about patient's wishes or best interests
Time pressure for urgent decisions limits thorough discussion
Complexity of interventions makes comprehensive disclosure challenging
Language barriers and health literacy issues
Emotional stress of family members impairs understanding and decision-making

Capacity Assessment

Definition and Scope:

Decision-making capacity is the ability to understand, appreciate, reason about, and communicate a choice
Distinct from competence (legal determination) and mental illness diagnosis
Decision-specific: a patient may have capacity for some decisions but not others
Time-specific: capacity can fluctuate with clinical condition
Presumption of capacity: adults are presumed to have capacity unless demonstrated otherwise

Legal Framework:

Varies by jurisdiction (Australian states/territories, New Zealand)
Generally: adults have right to make decisions about their own treatment
Exceptions: when capacity impaired, guardians may be appointed
Emergency treatment: may be provided without consent if urgent and necessary to prevent harm

Assessment Process:

Establish threshold question: Is there a genuine doubt about capacity?
- Patient's behavior, condition, or statements raise concern
- High-stakes decisions warrant more careful assessment
- Not necessary to assess capacity for every routine decision
Assess four domains (Grisso and Appelbaum):
- Understanding: Does patient comprehend relevant information?
  - Explain diagnosis, prognosis, treatment options
  - Ask patient to explain back in their own words
  - Assess ability to paraphrase and recall key points
- Appreciation: Does patient recognize how information applies to themselves?
  - "How will this treatment affect your life?"
  - "What are your concerns about this illness?"
  - Assess insight into personal implications
- Reasoning: Can patient weigh options rationally?
  - "What are the reasons for your decision?"
  - "What would happen if you chose the other option?"
  - Assess logical connection between values and choice
- Communication: Can patient express a stable choice?
  - Is the decision clear and consistent?
  - Can patient articulate their reasoning?
  - Is the decision sustained over time (for non-urgent decisions)?
Determine capacity:
- All four domains must be intact for full capacity
- Specific impairment: patient may lack capacity for particular decision
- Fluctuating capacity: may require reassessment
Document findings:
- Basis for capacity assessment
- Specific deficits identified
- Decision about capacity determination
- Plan for reassessment if capacity fluctuates

Common Causes of Impaired Capacity in ICU:

Delirium: acute confusional state, very common in ICU, impairs all domains
- "Prevalence: up to 80% of ICU patients"
- "Features: fluctuating awareness, inattention, disorganized thinking"
- "Management: treat underlying cause, minimize sedatives, reorient patient"
Sedation: impairs understanding, reasoning, and appreciation
- Intubated patients typically sedated for comfort and ventilator synchrony
- Daily sedation interruption (sedation holiday) allows capacity assessment
- Light sedation (RASS -1 to +1) may allow communication for important decisions
Hypoxia: impairs cognitive function
- Severe hypoxemia (PaO2 < 60 mmHg) typically impairs capacity
- Supplemental oxygen may restore capacity
Metabolic derangements:
- Acidosis, electrolyte abnormalities, uremia, hepatic encephalopathy
- Correct metabolic abnormalities before capacity assessment
Neurological injury:
- Stroke, traumatic brain injury, hypoxic-ischemic encephalopathy
- May cause permanent or temporary capacity impairment
Psychiatric conditions:
- Depression, schizophrenia, bipolar disorder
- May impair capacity depending on severity and stability
- Active psychosis typically impairs capacity

Special Populations:

Adolescents: capacity may develop earlier than legal age of consent
- "Mature minor doctrine: some jurisdictions allow competent adolescents to consent"
- Involving parents/guardians generally appropriate
Elderly: higher prevalence of cognitive impairment
- Dementia, delirium more common
- Capacity assessment more important
People with intellectual disability:
- Cannot assume incapacity based on diagnosis alone
- Assess capacity individually, use appropriate communication strategies

Capacity Assessment Tools:

MacArthur Competence Assessment Tool for Treatment (MacCAT-T):
- Semi-structured interview for capacity assessment
- Standardized questions assessing understanding, appreciation, reasoning
- Not widely used in ICU due to time constraints
Aid to Capacity Evaluation (ACE):
- Step-by-step guide for capacity assessment
- Structured questions for each domain
- More practical for bedside use
Clinical judgment: most common approach in ICU
- Informal assessment through conversation
- Less structured but more feasible in time-pressured environment

Decision-Specific Capacity:

Medical vs non-medical decisions: capacity may differ
- Patient may have capacity for treatment decisions but not financial decisions
- Specific assessment for each high-stakes decision
Complex vs simple decisions:
- More complex decisions require greater cognitive capacity
- Simple decisions (e.g., consent for blood test) may be possible even with mild impairment
Life-sustaining treatment: high stakes warrant careful capacity assessment

Fluctuating Capacity:

Common in ICU due to changing clinical condition
May be present at some times, absent at others
"Window of opportunity": assess capacity during lucid intervals
Document capacity at specific time, reassess if condition changes

Capacity to Refuse Treatment:

Same standard as capacity to consent
Patients have right to refuse treatment even if it leads to death
Exceptions: emergency treatment, mental health legislation (suicide prevention)
Clinicians may feel distressed by refusal of beneficial treatment
Seek ethics consultation if disagreement persists

When Capacity is Impaired:

Advance directives: check for prior written instructions or appointed surrogate
Substitute decision-maker: identify legally recognized surrogate
Best interests decision: make decision based on what would promote patient's welfare
Review: reassess capacity regularly as clinical condition changes
Ethics consultation: seek input for complex or disputed decisions

Advance Directives

Definition and Purpose:

Advance directives are legal documents that allow individuals to specify their treatment preferences or appoint a surrogate decision-maker in advance of losing decision-making capacity
Purpose: extend autonomy into future periods of incapacity, reduce burden on families, guide clinicians
Two main types: instructional directives (living wills) and proxy appointments (enduring powers of attorney)

Types of Advance Directives:

Living Will (Instructional Directive):
- Written statement of treatment preferences for future illness
- May specify conditions under which life-sustaining treatment would be refused
- Examples: "I do not want mechanical ventilation if I have terminal illness," "No dialysis if permanent unconscious"
- Limitations: cannot anticipate all possible clinical scenarios, may be vague or ambiguous
Enduring Power of Attorney (Medical Treatment):
- Appointment of surrogate decision-maker for medical decisions
- Takes effect when person loses capacity
- Surrogate makes decisions based on substituted judgment (what patient would want) or best interests
- More flexible than living will as surrogate can adapt to unanticipated circumstances
Combined Directives:
- Both treatment preferences and appointed surrogate in one document
- Most comprehensive approach

Legal Status in Australia:

Varies by state and territory
Generally recognized but specific requirements differ
Some jurisdictions: advance directive must be witnessed, registered, or meet formal requirements
Some jurisdictions: specific advance care planning documents with statutory force
All jurisdictions: have guardianship legislation for substitute decision-making

Legal Status in New Zealand:

Protection of Personal and Property Rights Act 1988
Enduring powers of attorney for personal care and welfare
Must be witnessed, comply with formal requirements
Advance directives (living wills) recognized but not specifically legislated

Validity and Interpretation:

Formal validity: meets legal requirements (witnessed, dated, signed, specific language)
Competence when made: person must have capacity when creating advance directive
Specificity: sufficiently specific to guide current clinical decision
Relevance: clinical situation matches scenario contemplated in advance directive
Revocation: can be revoked at any time while person has capacity (oral or written revocation)
Conflict with best interests: advance directive may specify treatment that appears against patient's best interests; ethical tension between autonomy and beneficence

Limitations of Advance Directives:

Incomplete information: person may not have adequate information when writing directive
Changing preferences: preferences may change over time, but directive remains static
Unanticipated scenarios: cannot anticipate all possible clinical situations
Ambiguity: vague language ("no heroic measures," "poor quality of life") difficult to interpret
Conflict with clinical judgment: directive may specify treatment clinicians believe is medically inappropriate
Family disagreement: family members may disagree about interpretation or validity

Advance Care Planning:

Broader process than advance directive document
Ongoing conversations about values, goals, and preferences
Includes family members, clinicians, and possibly cultural or spiritual advisors
Should be revisited periodically as health status or preferences change
Results in advance directive document, but also shared understanding

Advance Care Planning in ICU:

Challenging due to time pressure and urgency of decisions
Often occurs after ICU admission when patient already critically ill
Family meetings to elicit patient's known values and preferences
Focus on goals of care rather than specific treatment decisions

Special Considerations:

Cultural considerations:
- Some cultures avoid discussions of death and dying
- Family-centered decision-making vs individual autonomy
- May need to involve community or religious leaders
Mental illness: psychiatric condition does not necessarily invalidate advance directive unless impaired capacity at time of creation
Dementia: advance directive created after dementia diagnosis may be challenged if capacity questionable
Language barriers: ensure patient understands directive when created; use interpreters if needed

When Advance Directive is Absent:

Identify substitute decision-maker according to legal hierarchy
Apply substituted judgment standard: what would patient want based on known values and preferences?
Apply best interests standard: what promotes patient's welfare and quality of life?

Documentation:

Locate any advance directive documents in medical records or from family
Discuss with surrogate decision-maker whether advance directive exists
Document presence, absence, or uncertainty about advance directive
Document interpretation of advance directive and how it guides current decisions

Conflicts Involving Advance Directives:

Family vs directive: family members disagree with advance directive or claim it doesn't apply
Clinician vs directive: clinicians believe directive conflicts with best interests or medical appropriateness
Outdated directive: situation has changed since directive created, preferences may have changed
Unclear application: current clinical situation doesn't clearly match scenario contemplated in directive

Resolution Strategies:

Ethics consultation to clarify interpretation and ethical analysis
Multidisciplinary discussion to assess clinical appropriateness
Family meeting to discuss directive and concerns
Legal consultation in disputed cases (rarely necessary)
Time-limited trial of treatment if uncertainty about outcome

Surrogate Decision-Making

Definition and Purpose:

Surrogate decision-making occurs when a patient lacks decision-making capacity and another person makes medical decisions on their behalf
Purpose: extend patient autonomy when patient cannot speak for themselves
Surrogate should base decision on patient's known wishes or best interests

Surrogate Decision-Maker Hierarchy:

Varies by jurisdiction (Australian states/territories, New Zealand)
Generally follows this hierarchy:
1. Court-appointed guardian or administrator
2. Enduring power of attorney (medical treatment) appointed by patient
3. Spouse or domestic partner
4. Adult children
5. Parents
6. Siblings
7. Other relatives or friends
Guardian or public advocate may be appointed if no suitable surrogate available

Standards for Surrogate Decision-Making:

Substituted Judgment Standard:
- Surrogate makes decision based on what patient would have chosen
- Primary standard when patient's wishes can be determined
- Requires knowledge of patient's values, preferences, and prior statements
- Questions: "What would the patient want in this situation?" "What did they say about similar situations?"
- More consistent with respect for autonomy
Best Interests Standard:
- Surrogate makes decision based on what promotes patient's welfare
- Used when patient's wishes are unknown
- Factors: potential benefits and burdens of treatment, quality of life, relief of suffering
- More paternalistic but necessary when substituted judgment impossible

Hybrid Approach:

Most surrogates consider both substituted judgment and best interests
Ideal: evidence of patient's wishes guides decision; absence of evidence, consider best interests
Advance directives provide explicit evidence of substituted judgment

Challenges for Surrogates:

Emotional burden: making life-and-death decisions for loved one is stressful
Uncertainty about patient's wishes: may not have discussed specific scenarios
Guilt: worry about making "wrong" decision, feeling responsible for outcome
Family conflict: family members may disagree about what patient would want or what is in best interests
Pressure from clinicians: may feel influenced by clinicians' recommendations
Time pressure: urgent decisions may require rapid decisions without adequate reflection

Clinician Responsibilities with Surrogates:

Elicit patient's known preferences: ask surrogates about patient's values, prior statements, advance directives
Explain clinical situation: provide clear, understandable information about diagnosis, prognosis, treatment options
Support decision-making: allow time for questions, involve multiple family members if appropriate
Avoid coercion: present options neutrally, respect surrogate's decision even if clinicians disagree
Document discussions: record surrogate's decision and reasoning

SUPPORT Study Findings:

Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments
Demonstrated significant deficits in communication and decision-making in ICU
Key findings:
- Only 47% of physicians knew their patients' preferences about cardiopulmonary resuscitation
- "Surrogates overestimated survival rates: median predicted survival 75%, actual survival 11%"
- "Family meetings rarely documented: only 27% of deaths had documented discussion about limiting treatment"
- Patients frequently received unwanted aggressive treatment near end of life

Surrogates vs Clinicians:

Surrogates may have different perspectives on treatment decisions:
- More optimistic about prognosis
- More reluctant to withdraw life support
- More influenced by religious or cultural beliefs
Clinicians may overestimate benefits of aggressive treatment
Both surrogates and clinicians have biases and limitations
Shared decision-making aims to incorporate both perspectives

Special Situations:

Multiple surrogates: family members may disagree
- Identify legally recognized decision-maker
- Facilitate family consensus if possible
- Ethics consultation if conflict persists
No suitable surrogate: no family member or friend available
- Public advocate or guardian may be appointed
- Clinicians make best interests decision in emergency
Surrogate with conflict of interest: financial or other interest that may compromise decision
- Legal mechanisms to remove or replace surrogate in some jurisdictions
- Ethics consultation recommended

Legal Frameworks:

Guardianship legislation in each state/territory (Australia)
Protection of Personal and Property Rights Act (New Zealand)
Emergency treatment may proceed without surrogate consent if urgent and necessary
Surrogates generally have legal authority to make treatment decisions
Clinicians may appeal to guardianship tribunal if surrogate decision clearly not in patient's best interests

Conflict Resolution:

Family vs surrogate: family members disagree with surrogate's decision
- Identify legally recognized surrogate
- Facilitate family meeting to discuss concerns
- Ethics consultation if conflict persists
Surrogate vs clinician: surrogate chooses treatment clinicians believe inappropriate
- Clarify misunderstandings, provide additional information
- Ethics consultation to analyze ethical issues
- Time-limited trial of treatment if uncertainty about outcome
- Legal consultation in rare cases (guardianship tribunal)
Surrogate vs advance directive: surrogate decision conflicts with written advance directive
- Advance directive generally takes precedence if valid and applicable
- Surrogate may claim advance directive outdated or doesn't apply
- Ethics consultation to resolve

Medical Futility

Definition and Evolution:

Medical futility refers to treatment that provides no meaningful benefit to the patient
Concept has evolved from "futility" to "inappropriate treatment"
Increasing recognition that "futility" is value-laden and can be used to justify unilateral decisions

Types of Futility:

Quantitative Futility:
- Physiological impossibility of achieving treatment goals
- Probability of success vanishingly small (often defined as below 1%)
- Examples:
  - Cardiopulmonary resuscitation in septic shock with multi-organ failure where survival approaches zero
  - Ventilatory support for irreversible respiratory failure with no chance of recovery
  - Dialysis for end-stage renal failure with multi-organ failure and irreversible brain injury
- More objective, less controversial than qualitative futility
- Can be supported by evidence from studies or databases
Qualitative Futility:
- Treatment may maintain biological life but resulting quality of life is unacceptable
- Highly subjective and culturally dependent
- Examples:
  - Persistent vegetative state with no meaningful interaction or awareness
  - Advanced dementia with severe suffering and no prospect of recovery
  - Terminal illness with uncontrolled suffering despite palliative care
- Controversial: different individuals and cultures have different values about quality of life
- Clinicians' judgments about what constitutes acceptable quality of life may not reflect patient's values
Inappropriate Treatment (Preferred Contemporary Term):
- Treatment that is medically possible but ethically unjustifiable
- Emphasizes disproportionate burden relative to expected benefit
- Considers both quantitative and qualitative aspects
- Recognizes that "futility" has been used to justify unilateral decisions without patient/surrogate input

Challenges with Futility Determinations:

Value judgments: determinations of quality of life and acceptable benefit involve subjective values
Prognostic uncertainty: clinicians' predictions about outcomes are often imprecise
Cultural differences: values about quality of life vary across cultures
Conflict with autonomy: futility determinations may override patient/surrogate wishes
Potential for abuse: futility label may be used to ration resources or justify "giving up"

Evidence-Based Futility:

Use of objective criteria when possible
Examples:
- APACHE II scores, SOFA scores to predict mortality
- Specific conditions with known poor outcomes (e.g., cardiac arrest with greater than 20 minutes asystole)
- Palliative Performance Scale, Karnofsky Performance Status for functional assessment
Limitations:
- Predictive models are probabilistic, not deterministic
- Patients may be outliers to population averages
- Outcomes measured (survival, functional status) may not capture what matters to patient

Consensus vs Unilateral Decisions:

Consensus approach (preferred):
- Clinicians and surrogates agree that treatment is futile or inappropriate
- Based on shared understanding of prognosis and values
- Requires honest, compassionate communication about prognosis
- Ethics consultation may facilitate consensus
Unilateral decisions (problematic):
- Clinician declares treatment futile and unilaterally withholds or withdraws
- Surrogates strongly disagree, want continued treatment
- "Ethically fraught: conflicts with autonomy, risks paternalism"
- "May be justified only when:"
  - Quantitative futility clearly established (e.g., zero chance of benefit)
  - Treatment would impose significant burden without benefit
  - Exhausted consensus-building efforts, ethics consultation
  - Legal framework supports unilateral decisions (varies by jurisdiction)

Conflict Resolution in Futility Disputes:

Prognostic clarity: provide best available evidence about outcomes
Time-limited trial: continue treatment for defined period with clear goals and stopping criteria
Second opinion: another clinician's assessment of futility
Ethics consultation: multidisciplinary ethics committee provides structured analysis
Legal mechanisms: guardianship tribunal in some jurisdictions (rarely used)

Legal Frameworks:

Vary by jurisdiction
Some jurisdictions: clinicians may unilaterally withhold futile treatment
Some jurisdictions: require surrogates' consent even for futile treatment
Some jurisdictions: dispute resolution through ethics committees or tribunals
Generally trend toward consensus approach, avoiding unilateral decisions

Alternative Language:

"Inappropriate treatment" (Australian and New Zealand Intensive Care Society)
"Non-beneficial treatment"
"Medically inappropriate"
Avoids absolute language of "futility" while acknowledging disproportionate burden

Documentation:

Clear documentation of futility determination
Include: clinical evidence, prognostic data, discussion with surrogates, ethics consultation
Document consensus or ongoing disagreement

Ethical Analysis:

Consider all four principles:
- "Autonomy: respect patient/surrogate wishes unless treatment truly futile"
- "Beneficence: do not provide treatment with no meaningful benefit"
- "Non-maleficence: avoid imposing burdens without benefit"
- "Justice: avoid futile treatment that uses resources that could benefit others"

End-of-Life Ethics

Withholding vs Withdrawing Life-Sustaining Treatment:

Withholding: decision not to initiate a life-sustaining intervention
- "Example: not intubating patient with terminal illness who declines mechanical ventilation"
- Not starting dialysis in end-stage renal failure with multi-organ failure
Withdrawing: decision to discontinue an ongoing life-sustaining intervention
- "Example: extubating patient after determining mechanical ventilation is futile"
- Stopping dialysis or vasopressors when treatment no longer provides benefit
Ethical and legal equivalence:
- Both are decisions not to provide treatment
- Withdrawing is not "killing" any more than withholding
- Both decisions based on assessment that treatment burden outweighs benefit
Psychological differences:
- Clinicians and families often experience greater emotional difficulty with withdrawal
- Withdrawal feels more like "causing death" than withholding
- Requires careful communication about ethical and legal equivalence

Double Effect Doctrine:

Principle: an action with both good and bad effects may be ethically permissible if:
1. The action itself is morally good or neutral
2. The bad effect is not intended but merely foreseen
3. The bad effect is not the means to achieve the good effect
4. The good effect outweighs the bad effect
Application in end-of-life care:
- Administering opioids or benzodiazepines to relieve pain or dyspnea, which may hasten death as a foreseen but unintended side effect
- Primary intent is symptom relief, not causing death
- Ethically permissible under double effect doctrine
- Distinct from euthanasia or physician-assisted dying where primary intent is causing death
Clinical practice:
- Opioid doses titrated to relieve symptoms, not to cause respiratory depression
- Monitoring for oversedation and respiratory depression
- Adjusting doses based on symptom response
- Documentation of intention (symptom relief vs hastening death)

Proportionality:

Treatment burden must be proportional to expected benefit
Invasive interventions justified only when benefit outweighs harm
Considerations: likelihood of success, magnitude of benefit, duration of benefit, treatment burden, patient's values
Examples:
- "Mechanical ventilation: justified if patient has good chance of recovery to acceptable quality of life"
- "Dialysis: justified if patient has reasonable chance of survival or acceptable quality of life"
- "Cardiopulmonary resuscitation: generally not justified if prognosis is very poor"

Terminal Weaning vs Terminal Extubation:

Terminal weaning: gradual reduction of ventilatory support with aggressive symptom management
- Slowly reducing pressure support, FiO2, or respiratory rate
- Patient may breathe spontaneously for some time before death
- Allows family more time with patient, may reduce psychological distress
- Requires careful symptom management (anxiety, dyspnea, secretions)
Terminal extubation: immediate removal of endotracheal tube
- Patients extubated to room air or non-invasive ventilation
- More rapid death in most patients
- May be preferred for patients intolerant of ventilator or with significant secretions
- Requires pre-extubation sedation and analgesia to prevent distress
Choice depends on:
- Patient's preferences (if known)
- Clinical factors (secretions, tolerance of ventilator)
- Family preferences and emotional capacity
- Institutional practices and experience

Symptom Management at End of Life:

Pain: opioids (morphine, fentanyl, hydromorphone), titrated to effect
Dyspnea: opioids, oxygen if hypoxemic, fans for air movement, benzodiazepines for anxiety
Anxiety/agitation: benzodiazepines (midazolam, lorazepam)
Secretions: anticholinergics (glycopyrrolate, hyoscine) to reduce oral secretions
Myoclonus: benzodiazepines, other medications if needed
Documentation: doses, indications, response, intention (symptom relief)

Organ Donation after Circulatory Death (DCD):

Controlled DCD: withdrawal of life support followed by organ donation after circulatory death
- Requires clear separation between end-of-life decision and donation decision
- Decision to withdraw must be independent of donation considerations
- No touching or manipulation of patient until death declared
Ethical considerations:
- Ensure withdrawal decision not influenced by donation
- Ensure consent for donation separate from consent for withdrawal
- Ensure no conflict between end-of-life care and donor management
- Ensure death determination is unequivocal

Palliative Sedation:

Continuous sedation for refractory symptoms at end of life
Indicated for severe, intractable symptoms (pain, dyspnea, agitation) not controlled by other measures
Goal: relief of suffering, not causing death
Ethically distinct from euthanasia: proportionate to symptom severity, not intended to cause death
May be controversial when sedation continued until death

Documentation Requirements:

Comprehensive documentation of decision-making process
Include: clinical information, prognosis, discussion with patient/surrogate, consensus, goals of care
Document withdrawal or withholding decisions clearly
Document symptom management plan and medications
Document family communication and their understanding

Legal Considerations:

Withholding and withdrawing treatment generally legal when based on patient's wishes or best interests
Distinct from euthanasia (legal in some jurisdictions) and physician-assisted dying (legal in some jurisdictions)
Legal frameworks vary by jurisdiction
Generally: intention (relieve suffering vs cause death) is key distinction

Resource Allocation

Distributive Justice:

Justice requires fair distribution of benefits, burdens, and resources
ICU resources (beds, ventilators, staff, drugs) are scarce, requiring allocation decisions
Triage: process of sorting patients according to need and likelihood of benefit

Ethical Frameworks for Allocation:

Utilitarianism: maximize overall good (lives saved, life-years saved)

Prioritize patients with highest likelihood of benefit or most life-years gained
"Controversial: may disadvantage elderly or those with chronic conditions"
Pandemic triage often uses SOFA score to predict mortality

Egalitarianism: treat everyone equally, random selection if insufficient resources

First-come-first-served
Lottery system
"Controversial: may not maximize lives saved"

Prioritarianism: prioritize worst-off

Sickest patients get priority
"Fair innings: everyone deserves some minimum of life-years"
"Controversial: may allocate resources to patients with poor prognosis"

Social utility: prioritize patients instrumental to social good

Healthcare workers during pandemic
"Controversial: may discriminate based on occupation"

Pandemic Triage:

Crisis standards of care: when demand exceeds supply, shift from patient-centered to population-centered ethics
SOFA-based triage: prioritize patients with lowest SOFA scores (better prognosis)
Exclude criteria: very poor prognosis regardless of treatment (SOFA > 11, multi-organ failure)
Appeal process: allow review of triage decisions
Ethically challenging: requires shift from focusing on individual patient to population benefit

Everyday Triage:

ICU admission triage: which patients benefit from ICU admission?
- "Likelihood of benefit: patients who will survive with ICU care but die without it"
- "Benefit magnitude: survival to discharge, functional recovery, quality of life"
- "Prognostic tools: APACHE II, SOFA, clinical judgment"
Interhospital transfer: transfer patients to other hospitals with ICU capacity
- Prioritize stable patients who can safely be transferred
- Consider prognosis and likelihood of benefit from transfer

Fair Innings Argument:

Everyone deserves opportunity for a complete lifespan
Prioritize younger patients who haven't had their "fair innings"
Controversial: discriminates based on age, may undervalue elderly lives

Procedural Justice:

Fair process for allocation decisions
Transparent criteria applied consistently
Opportunities for appeal and review
Multidisciplinary decision-making
Public engagement in developing allocation policies

Triage Officers:

Clinicians not directly caring for patients make triage decisions
Reduces moral distress for bedside clinicians
Ensures consistent application of criteria
Requires training and support

Ethical Tensions:

Individual vs population: balancing benefit to individual patient vs benefit to population
Short-term vs long-term: immediate survival vs long-term outcomes
Quality vs quantity of life: survival vs functional recovery and quality
Fairness vs utility: equal treatment vs maximizing outcomes

Conflict of Interest in Allocation:

Clinicians' duty to individual patient vs duty to population
Pressure to admit patients who may not benefit
Institutional pressures (revenue, reputation) influencing admission decisions

Legal and Ethical Obligations:

Duty of care: clinicians have duty to provide care to patients under their care
No duty to admit all patients: cannot provide ICU care to all who request it
Triage decisions based on clinical judgment and ethical principles, not discrimination

Resource Allocation in Low-Resource Settings:

Remote and regional ICUs: limited capacity, longer transfer times
International contexts: very limited resources, more challenging triage decisions
Ethical frameworks adapted to local context and resource constraints

Documentation:

Document triage decision and reasoning
Use standardized scoring systems when applicable
Document prognosis, likelihood of benefit, alternative options

Conflict of Interest

Definition:

Conflict of interest exists when a professional has a primary interest (patient welfare) and a secondary interest (financial, professional, personal) that may compromise judgment
Primary interest in medicine: patient welfare, professional integrity
Secondary interests: financial gain, career advancement, research goals, relationships

Types of Conflicts:

Financial conflicts:
- Pharmaceutical industry relationships: honoraria, consulting fees, research funding
- Industry-sponsored research: financial incentives for enrollment, publication
- Own financial interests: ownership in device or drug companies
- Institutional financial interests: revenue from particular procedures or treatments
Research conflicts:
- Pressure to enroll patients in studies
- Conflict between research goals and patient welfare
- Publication bias: only positive results published
Personal relationships:
- Treating family members or friends
- Dual relationships (doctor-patient and other relationship)
- Religious or cultural affiliations influencing care
Institutional pressures:
- Pressure to reduce length of stay, increase throughput
- Pressure to use particular treatments or protocols
- Financial incentives for quality metrics

Impact on Clinical Practice:

Prescribing behavior: influenced by industry relationships
Treatment decisions: biased by research participation or institutional pressures
Resource use: influenced by financial considerations
Communication: biased presentation of options to patients

Management of Conflicts of Interest:

Disclosure: transparent reporting of potential conflicts
Recusal: removing oneself from decision-making when conflict exists
Institutional policies: guidelines for managing conflicts
Regulation: legal requirements for disclosure in some jurisdictions
Education: training for clinicians about conflicts of interest

Pharmaceutical Industry Relationships:

Financial relationships: consulting, speaking, research funding
Evidence of influence: industry-sponsored research more likely to report favorable outcomes
Gifts and hospitality: even small gifts can influence behavior
Guidelines: professional societies recommend limits on industry relationships

Research Ethics:

Informed consent: patients must understand research purpose and alternatives
Therapeutic misconception: patients may confuse research with treatment
Data safety monitoring: oversight to protect patient welfare
Publication ethics: avoid ghostwriting, disclose conflicts

Professional Boundaries:

Avoid treating family members unless emergency
Avoid dual relationships (e.g., treating employee)
Maintain professional distance while providing compassionate care

Institutional Conflicts:

Quality metrics: incentives to achieve targets may influence care
Financial incentives: pressure to increase revenue or reduce costs
Reputation: pressure to maintain good outcomes may influence admission or discharge decisions

Ethical Analysis:

Autonomy: ensure patients receive unbiased information to make informed decisions
Beneficence: ensure clinical decisions based on patient welfare, not secondary interests
Non-maleficence: avoid harm caused by biased decisions
Justice: ensure fair access to care, not influenced by financial considerations

Legal and Regulatory Frameworks:

Disclosure requirements in many jurisdictions
Some restrictions on certain relationships (e.g., industry gifts)
Professional codes of conduct address conflicts of interest
Institutional review boards for research ethics

Ethics Consultation

Purpose:

Ethics consultation provides structured analysis of complex ethical issues
Multidisciplinary approach to ethical decision-making
Facilitates communication and conflict resolution
Supports clinicians, patients, and families in difficult decisions

When to Request Ethics Consultation:

Unclear or conflicting ethical principles
Disagreement between family members about treatment decisions
Disagreement between clinicians and family about treatment decisions
Disagreement among clinicians about appropriate care
Questions about capacity or surrogate decision-making
Questions about medical futility or inappropriate treatment
Complex end-of-life decisions
Questions about resource allocation or triage
Cultural or religious considerations affecting care

Ethics Committee Composition:

Multidisciplinary: physicians, nurses, allied health, ethicists, chaplains, community members
Diversity of perspectives to ensure comprehensive analysis
Some members have formal ethics training
Some members are laypersons from community

Ethics Consultation Process:

Referral: clinician, family, or patient requests consultation
Information gathering:
- Review medical record
- Interview clinicians caring for patient
- Interview patient (if capacity allows) or family/surrogate
- Understand clinical situation, prognosis, values, preferences
Ethical analysis:
- Identify ethical principles involved
- Identify conflicts between principles
- Consider legal frameworks
- Consider cultural factors
Recommendations:
- Provide ethical analysis and recommendations
- Non-binding: recommendations advisory, final decision remains with treating team
- Facilitate consensus-building among stakeholders
Documentation:
- Document consultation in medical record
- Include ethical analysis and recommendations

Benefits of Ethics Consultation:

Structured analysis of complex issues
Reduction in time on life-sustaining therapy
Improved satisfaction among clinicians and families
Resolution of conflicts
Education for clinicians and families about ethical principles

Limitations of Ethics Consultation:

Non-binding: may not resolve conflicts if parties unwilling to accept recommendations
Time-consuming: may delay decisions
May not be available in all institutions, especially smaller hospitals
May be perceived as adversarial

Evidence Base:

Studies demonstrate ethics consultations reduce length of stay on mechanical ventilation
Reduced ICU length of stay and hospital length of stay
Improved communication and conflict resolution
Cost-effective: reduction in unnecessary treatment offsets consultation cost

Cultural Competence in Ethics Consultation:

Awareness of cultural values and beliefs affecting decision-making
Involvement of cultural or spiritual advisors as appropriate
Respect for family-centered decision-making in some cultures
Adaptation of ethical principles to cultural context

Legal Considerations:

Ethics consultation recommendations generally advisory
Legal frameworks may override ethical recommendations in some cases
Legal consultation may be needed in rare cases

Legal Frameworks

Australian Legal Framework:

Varies by state and territory
Generally based on common law and guardianship legislation
Key principles:
- Competent adults have right to refuse treatment
- Advance directives recognized if meet formal requirements
- Substitute decision-makers have authority to make decisions for incapacitated patients
- Guardians may be appointed if no suitable surrogate
- Clinicians may provide emergency treatment without consent if urgent and necessary

State/Territory Legislation:

New South Wales: Guardianship Act 1987, Powers of Attorney Act 2003
Victoria: Medical Treatment Act 1988, Guardianship and Administration Act 1986
Queensland: Guardianship and Administration Act 2000, Powers of Attorney Act 1998
Western Australia: Guardianship and Administration Act 1990
South Australia: Guardianship and Administration Act 1993
Tasmania: Guardianship and Administration Act 1995
Australian Capital Territory: Medical Treatment (Health Directions) Act 2006
Northern Territory: Adult Guardianship Act 2016

Advance Care Planning:

National Advance Care Planning capacity-building initiative
Advance Care Planning Australia provides resources and guidelines
Recognizes Advance Care Directives in some jurisdictions

New Zealand Legal Framework:

Protection of Personal and Property Rights Act 1988:
- Establishes enduring powers of attorney for personal care and welfare
- Court may appoint welfare guardian if no suitable attorney available
- "Section 11B: refusal of medical treatment"
Code of Health and Disability Services Consumers' Rights:
- "Right 7: right to make informed choice and give informed consent"
- "Right 7(4): right to refuse treatment"
Palliative Care Act 2015:
- Establishes framework for advance care planning
- Recognizes advance directives
End of Life Choice Act 2019:
- Legalizes assisted dying for eligible terminally ill patients
- Strict eligibility criteria and safeguards

Common Law Principles:

Adults presumed to have capacity unless proven otherwise
Competent adults have right to refuse treatment (even life-saving treatment)
Withholding and withdrawing treatment ethically equivalent
Double effect doctrine recognized in common law
No legal duty to provide futile or inappropriate treatment

Emergency Treatment:

May proceed without consent if urgent and necessary to prevent death or serious harm
Doctrine of necessity
Implied consent in emergency situations

Guardianship:

Guardians or administrators appointed by court for people lacking capacity
May have authority to make medical decisions
Varies by jurisdiction

Legal Cases:

Re B (Consent to Treatment: Capacity) [2002]: adult with capacity has right to refuse treatment even if irrational
Re A (Children) (Conjoined Twins: Surgical Separation) [2001]: best interests of child vs religious beliefs
In re Quinlan (1976): right to refuse life-sustaining treatment, substituted judgment standard
Cruzan v. Director, Missouri Department of Health (1990): right to refuse treatment, clear and convincing evidence of patient's wishes required

Documentation Requirements:

Consent discussions documented in medical record
Advance directives located and reviewed
Capacity assessments documented
End-of-life decisions thoroughly documented
Ethics consultations documented

Medical Defense:

Clinicians protected if follow legal and ethical guidelines
Good communication and documentation key to avoiding legal problems
Ethics consultation provides evidence of thorough decision-making

Cultural Considerations

Indigenous Australians:

Cultural values:
- Family and community central to decision-making
- Importance of Sorry Business (mourning rituals)
- Passing away on Country (traditional lands)
- Respect for Elders
- Spiritual beliefs about death and dying
Decision-making:
- Family consensus rather than individual autonomy
- Elders (kaurna, kaumātua) important in decision-making
- Yarning (storytelling) as communication style
- "Time: decisions may require time for family consultation and consensus"
End-of-life care:
- Preference for palliative care over aggressive treatment
- Importance of family presence
- Cultural ceremonies (smoking ceremonies) before and after death
- Avoidance of certain topics may be culturally appropriate
Health disparities:
- Higher rates of chronic disease
- Lower life expectancy (8-10 years less than non-Indigenous Australians)
- Less access to specialist care
- Higher rates of ICU admission for preventable conditions
Communication:
- Use Aboriginal Health Workers or Aboriginal Liaison Officers
- Respect for silence and indirect communication
- Family meetings may include many family members
- Avoid medical jargon, use plain language

Māori (New Zealand):

Tikanga (cultural practices):
- Whānau (family) central to decision-making
- Kaumātua (elders) provide guidance
- Importance of tikanga (customary practices) in healthcare
- Tapu (sacredness) of body and death
Decision-making:
- "Whānau-centered: extended family involved in decisions"
- Hui (meetings) for decision-making with whānau
- kaumātua respected for wisdom and guidance
- "Time: may need time for whānau consultation and hui"
End-of-life care:
- Importance of dying at home or on marae
- Cultural protocols around death (tangihanga)
- Involvement of kaumātua and whānau
- Respect for wairua (spiritual wellbeing)
Te Tiriti o Waitangi obligations:
- "Partnership: Māori involved in healthcare decision-making"
- "Protection: protection of Māori health and wellbeing"
- "Participation: Māori participation in healthcare delivery"
Communication:
- Use of te reo Māori where appropriate
- Respect for cultural protocols and customs
- Family presence and involvement

CALD (Culturally and Linguistically Diverse) Populations:

Language barriers:
- Use professional interpreters (not family members)
- Plain language and avoid medical jargon
- Check understanding using teach-back method
- Written materials in appropriate languages
Cultural values:
- Family-centered vs individual autonomy
- Religious beliefs influencing treatment decisions
- Cultural attitudes toward death and dying
- Hierarchy and authority within families
Decision-making:
- Identify key decision-maker within family (may not be patient)
- Involve family members as appropriate
- Respect cultural protocols and customs
- Time may be needed for family consultation
Specific cultural considerations:
- "Muslim: Ramadan fasting may affect treatment timing, gender considerations"
- "Hindu: religious beliefs about end-of-life care"
- "Chinese: filial piety, family decision-making"
- "Other: specific cultural or religious practices"

Religious Considerations:

Christianity:
- Sanctity of life
- Death as transition to afterlife
- Some denominations oppose euthanasia but accept withholding futile treatment
Islam:
- Sanctity of life
- Acceptance of God's will
- Autonomy balanced with family decision-making
- Specific practices regarding autopsy, organ donation
Buddhism:
- Impermanence of life
- Avoidance of harm
- Compassion central
- Acceptance of death
Hinduism:
- Karma and dharma
- Sacredness of life
- End-of-life practices vary by region

Cultural Competence:

Awareness of own cultural assumptions and biases
Respect for diverse cultural values and practices
Adaptation of communication style to cultural context
Involvement of cultural or spiritual advisors when appropriate
Avoidance of stereotypes, recognition of individual variation

Assessment Practice

SAQ 1: Ethical Analysis of Medical Futility Dispute

Question: A 72-year-old woman with metastatic ovarian cancer is admitted to ICU with septic shock and multi-organ failure. She has been critically ill for three weeks with no improvement. The ICU team believes treatment is futile and recommends withdrawal of mechanical ventilation and vasopressors. The patient's daughter, as surrogate decision-maker, insists on continued treatment, stating that her mother is "a fighter" and has always wanted to live as long as possible. The daughter is angry and accuses the team of "giving up" on her mother.

Discuss the ethical principles involved, define medical futility, and outline a structured approach to managing this conflict. (15 marks)

Model Answer:

Ethical Principles (4 marks):

Autonomy: Respect for patient's self-determination and right to make decisions about her own care. The daughter, as surrogate, should base decision on patient's known wishes (substituted judgment standard).
Beneficence: Obligation to act in patient's best interest. Continued treatment may not be in patient's interest if prognosis is extremely poor.
Non-maleficence: Obligation to avoid harm. Continuing invasive treatment may cause suffering without meaningful benefit.
Justice: Fair use of resources. Prolonged futile treatment may divert resources from other patients with better prognosis.

Definition of Medical Futility (3 marks):

Quantitative futility: Physiological impossibility of achieving treatment goals; probability of success vanishingly small (below 1%). In this case, poor response to three weeks of aggressive treatment suggests very low probability of survival.
Qualitative futility: Treatment maintains biological life but quality of life would be unacceptable. More subjective and value-laden.
Inappropriate treatment: Current preferred term. Treatment may be medically possible but ethically unjustifiable due to disproportionate burden relative to expected benefit.

Structured Approach to Conflict Management (8 marks):

Assess Prognostic Certainty (1 mark)
- Review objective data: SOFA/APACHE scores, organ function trends, response to therapy
- Consider second opinion from independent intensivist
- Acknowledge prognostic uncertainty but present best available evidence
Establish Communication (1 mark)
- Schedule dedicated family meeting with core team and daughter
- Ensure all key clinicians present (intensivist, nursing, social work)
- Allocate adequate time, avoid interruptions
Elicit Patient's Known Wishes (1 mark)
- Ask daughter about mother's values, prior statements about end-of-life care
- Ask: "What did your mother say about life-sustaining treatment in similar situations?"
- Explore: "What mattered most to your mother in her life?" "How would she feel about her current condition?"
Provide Clear, Compassionate Information (1 mark)
- Explain clinical situation: severity of illness, prognosis (with data), uncertainty
- Explain treatment options: continued intensive care vs comfort-focused care
- Explain benefits and burdens of each option
- Use plain language, check understanding with teach-back
Empathetic Response to Daughter's Anger (1 mark)
- Acknowledge daughter's love for her mother and desire to advocate
- Validate her feelings: "I can see this is incredibly difficult. You want to do everything possible for your mother."
- Avoid defensiveness: clarify that "not giving up" is different from "treatment is futile"
Explore Substituted Judgment vs Best Interests (1 mark)
- If patient's wishes known (e.g., advance directive, prior statements), apply substituted judgment
- If wishes unknown, discuss what would be in patient's best interests based on values
- Ask: "What would your mother want if she could speak for herself now?"
Time-Limited Trial of Treatment (1 mark)
- If uncertainty persists about prognosis, propose time-limited trial
- Define clear goals and stopping criteria (e.g., "Continue treatment for 3 days, reassess hemodynamic response")
- Ensure daughter agrees to trial and understands stopping criteria
Ethics Consultation (0.5 mark)
- If conflict persists after above steps, request formal ethics consultation
- Provides structured analysis, may facilitate consensus
- Recommendations advisory, final decision with treating team
Documentation (0.5 mark)
- Document discussions, prognosis data, patient's wishes (if known), daughter's position
- Document goals of care and plans for ongoing management
- Document ethics consultation if requested

SAQ 2: Capacity Assessment and Surrogate Decision-Making

Question: A 68-year-old man is admitted to ICU with severe community-acquired pneumonia requiring mechanical ventilation. He is intubated and sedated with midazolam and fentanyl. He has a history of schizophrenia, well-controlled on antipsychotic medications, but has not had any psychotic symptoms for many years. His wife, with whom he has lived for 40 years, tells the team that her husband has an advance directive stating he does not want mechanical ventilation if he is unlikely to return to independent living. She produces a document signed three years ago stating: "If I am in a state where I am unlikely to return to independent living, I do not want to be kept alive on machines." The ICU team believes his prognosis is good with greater than 80% chance of recovery, and he should continue mechanical ventilation.

Discuss the capacity assessment, the validity of the advance directive, and the appropriate decision-making process in this scenario. (15 marks)

Model Answer:

Capacity Assessment (4 marks):

Current capacity: Patient currently lacks capacity due to intubation and sedation for mechanical ventilation. Sedation impairs understanding, appreciation, reasoning, and communication of decisions. Capacity should be reassessed after sedation is minimized or weaned.
Capacity at time of advance directive: Patient signed advance directive three years ago. Capacity at that time requires assessment. History of well-controlled schizophrenia does not automatically imply lack of capacity. Key considerations:
- Was patient free from acute psychotic symptoms at time of signing?
- Was patient adequately informed about implications of directive?
- Did patient understand the document and its implications?
- Was the decision voluntary, without coercion?
- Wife's testimony about patient's capacity at that time is supportive evidence.
Specific vs global capacity: Capacity is decision-specific. Patient may have capacity for financial decisions but impaired capacity for medical decisions at time of ICU admission.

Validity of Advance Directive (5 marks):

Formal validity (2 marks):

Document signed and dated three years ago (meets basic formal requirements)
Should be witnessed (check if witnessed; not mentioned in scenario)
May need to comply with state/territory legislation (specific requirements vary)

Substantive validity (2 marks):

Applicability: Current situation must match scenario contemplated in directive. Directive states condition: "unlikely to return to independent living." Prognosis greater than 80% chance of recovery suggests patient likely to return to independent living. Directive may not apply.
Clarity: Directive is relatively clear and specific about condition and preference (no mechanical ventilation).
Relevance: If patient likely to return to independent living, directive's condition not met. Treatment consistent with patient's preferences may be to continue ventilation.
Changing preferences: Possibility that preferences changed in three years. Wife's testimony about current wishes important.

Conflict with clinical judgment (1 mark):

Clinicians believe patient should continue ventilation (good prognosis)
If directive's condition not met (patient likely to recover), no conflict
If directive interpreted as applying despite good prognosis, ethical tension between autonomy and beneficence

Decision-Making Process (6 marks):

Clarify Prognosis (1 mark)
- Obtain most accurate prognosis estimate (80% chance of recovery)
- Determine likelihood of returning to independent living
- If prognosis excellent (greater than 80% recovery), advance directive's condition not met
Interpret Advance Directive (1 mark)
- Determine if current situation matches scenario contemplated in directive
- "Unlikely to return to independent living": prognosis good suggests likely to return to independent living
- If condition not met, directive does not apply; treatment decision should be based on other factors
Elicit Current Wishes (1 mark)
- Discuss with wife about any conversations since directive was signed
- Ask: "Did your husband ever say anything that suggests his views changed?"
- Explore whether patient would want treatment given excellent prognosis
Apply Standards (1 mark)
- Substituted judgment: Based on patient's known wishes (advance directive, prior statements). If directive not applicable, consider prior conversations.
- Best interests: If substituted judgment impossible, consider what promotes patient's welfare (survival with good prognosis)
- Given excellent prognosis, both substituted judgment and best interests likely support continued ventilation
Family Meeting (1 mark)
- Schedule meeting with wife to discuss prognosis, advance directive, treatment plan
- Present clear information about prognosis and likelihood of returning to independent living
- Explore wife's concerns and understanding
- Seek consensus about treatment plan
Reassess Capacity (1 mark)
- Minimize sedation if possible to assess patient's current wishes
- Daily sedation interruption may allow patient communication
- If patient regains capacity, involve directly in decision-making
Documentation (not scored but important):
- Document advance directive, its interpretation, rationale for treatment decision
- Document family discussion and consensus

Decision: Given excellent prognosis (greater than 80% chance of recovery) and high likelihood of returning to independent living, advance directive's condition not met. Continue mechanical ventilation consistent with both substituted judgment (patient's presumed wishes given good prognosis) and best interests (survival with good recovery).

Examiner: We're going to discuss a case. A 55-year-old woman with severe community-acquired pneumonia is admitted to ICU. She's hypoxemic, confused, and requires urgent intubation. Her husband is present and consent is sought for intubation and mechanical ventilation. The husband refuses consent, stating that his wife would not want "to be hooked up to machines." The patient's oxygen saturation is dropping rapidly, and she's becoming obtunded. How do you approach this situation?

Candidate: This is an urgent situation requiring immediate intervention to prevent death or serious harm. Key ethical principles to consider are autonomy (respect for patient's wishes), beneficence (acting in patient's best interest), non-maleficence (avoiding harm), and justice (fair use of resources).

Examiner: Tell me about the concept of implied consent.

Candidate: Implied consent applies in emergency situations where patient lacks capacity and urgent treatment is necessary to prevent death or serious harm. The patient is presumed to consent to treatment that a reasonable person would want in that situation. In this case, with rapidly dropping oxygen saturation and obtundation, intubation is urgently needed to prevent death or anoxic brain injury. A reasonable person would want life-saving treatment in this situation.

Examiner: But the husband is refusing consent as surrogate. Doesn't that create a problem?

Candidate: The husband's refusal must be respected, but it must be informed and based on the patient's known wishes, not his own wishes or misunderstanding of the situation. Key questions: Does the husband have valid authority as surrogate decision-maker? In most jurisdictions, spouses have this authority. Is his refusal based on the patient's known wishes (substituted judgment) or his own beliefs?

Examiner: Let's say he tells you the patient has an advance directive stating she doesn't want mechanical ventilation. What then?

Candidate: Then I need to see the advance directive and assess its validity and applicability. Validity: Is it properly signed and witnessed? Applicability: Does the current situation match the scenario contemplated in the directive? For example, does the directive apply to temporary treatment for reversible illness like pneumonia, or only to irreversible conditions? Many advance directives distinguish between temporary treatment for reversible illness and permanent support for irreversible conditions.

Examiner: The directive simply states "I do not want to be on a breathing machine under any circumstances." What do you do?

Candidate: This is challenging. The directive is clear and specific (good), but the "under any circumstances" language creates problems. If applied literally, it would mean refusing temporary, life-saving treatment for reversible illness. This seems inconsistent with a reasonable person's preferences. Ethical tension between autonomy (respecting advance directive) and beneficence (preventing avoidable death).

I would:

Ask the husband about the context: When did she write this? Did she understand it would apply to reversible, temporary illness like pneumonia?
Consider whether the patient's capacity at time of signing was adequate (understanding implications)
Clarify the acute nature and prognosis: excellent chance of full recovery with temporary ventilation
If husband maintains refusal despite this information, request urgent ethics consultation

Examiner: The patient's oxygen saturation is now 75% and she's unresponsive. The husband is adamant: "She said no machines, no machines." What do you do?

Candidate: This is an emergency. The patient will die or suffer permanent anoxic brain injury without immediate intubation. I would proceed with intubation based on:

Doctrine of implied consent in life-threatening emergency
The directive's "under any circumstances" language likely resulted from lack of understanding; patient probably did not intend to refuse temporary, life-saving treatment for reversible illness
Husband's refusal appears to be based on a literal interpretation rather than substituted judgment reflecting patient's considered values
Beneficence and non-maleficence support intervention to prevent death and harm

I would:

Inform the husband that we are proceeding with intubation to save his wife's life
Explain that this is an emergency and we believe his wife, if able to speak for herself, would want temporary treatment for reversible illness
Offer to have him speak with an ethics consultant or pastoral care after the patient is stabilized
Document the situation, husband's refusal, rationale for proceeding

Examiner: After intubation, the patient stabilizes and improves. On day 3, you sedation-holiday her, and she wakes up, appears to have capacity, and states she does not want to be on the ventilator and wants it removed immediately. What do you do?

Candidate: Now the patient has capacity and is expressing her wishes directly. This changes the situation. Key questions:

Does she understand her condition, prognosis, and alternatives?
Does she appreciate the personal implications (she will die if extubated without resolution of pneumonia)?
Is she reasoning through the decision rationally, or is this an impulsive decision influenced by anxiety or delirium?
Is her communication clear and stable?

I would:

Conduct a formal capacity assessment using the four domains: understanding, appreciation, reasoning, communication
Provide clear information about her condition (pneumonia improving but not resolved), prognosis (good chance of recovery with continued ventilation, high risk of death if extubated now)
Explore her reasons: Is she uncomfortable on the ventilator? Anxious? Does she misunderstand her prognosis?
If she lacks capacity (e.g., delirium, impaired reasoning), I would not extubate but would continue treatment and reassess capacity
If she has capacity and makes an informed decision to refuse life-sustaining treatment, I must respect her autonomy. This would require:
- Confirming her understanding that she will likely die if extubated
- Ensuring her decision is voluntary (no coercion, depression, delirium)
- Documenting her decision and capacity assessment
- Involving ethics consultation given the gravity of the decision
- Providing comfort-focused care if she chooses extubation

Examiner: You assess her capacity and find she understands she will die if extubated, but she is firm: "I lived a good life, I don't want to be on this machine anymore. I'm done." She is not depressed or delirious. Do you extubate?

Candidate: If I am confident she has capacity (understanding, appreciation, reasoning, communication all intact) and her decision is informed and voluntary, I must respect her autonomous decision to refuse life-sustaining treatment. This is ethically and legally supported.

However, I would take additional steps:

Explore further: Has she said this before? Does she have an advance directive? Are there religious or cultural factors?
Involve her husband and family: Understand their perspectives, ensure the patient is not under pressure
Request ethics consultation: Provide structured analysis and support for this difficult decision
Ensure adequate symptom management: If extubated, provide comfort measures to prevent suffering
Document thoroughly: Capacity assessment, patient's decision, family discussion, ethics consultation

This would be a withdrawal of life-sustaining treatment based on patient's autonomous refusal, not euthanasia. The intention is to respect her autonomy, not to cause death.

Examiner: What if her husband says, "You can't let her die! Do everything possible!"?

Candidate: The husband's wishes do not override the patient's autonomous decision if she has capacity. However, I would:

Facilitate communication between the patient and her husband
Ensure the patient's decision is truly her own, not influenced by family conflict
Offer additional time for the family to discuss
If the patient maintains her decision despite husband's objections, I would proceed with withdrawal while supporting the family
Offer counseling, chaplaincy support, and opportunities for family to be present

Viva 2: End-of-Life Ethics and Resource Allocation

Examiner: Let's discuss a different scenario. You're working in a 20-bed regional ICU during a severe influenza outbreak. All beds are occupied. A 45-year-old woman with no comorbidities presents with viral pneumonia and respiratory failure requiring mechanical ventilation. She has a 20-year-old child. At the same time, a 75-year-old man with metastatic lung cancer presents with septic shock from pneumonia. He also needs mechanical ventilation. You have one bed available. Who do you admit to ICU? How do you make this decision?

Candidate: This is a triage situation requiring fair allocation of scarce resources. Key ethical principles: justice (fair distribution), beneficence (maximizing benefit), non-maleficence (avoiding harm), and autonomy (respecting patient wishes, though limited by resource constraints).

Examiner: What ethical frameworks guide resource allocation decisions?

Candidate: Several frameworks:

Utilitarianism: Maximize overall good. Prioritize patients with highest likelihood of benefit or most life-years gained.
Egalitarianism: Treat everyone equally. First-come-first-served or random selection.
Prioritarianism: Prioritize worst-off. Fair innings argument.
Social utility: Prioritize patients instrumental to social good (healthcare workers during pandemic).

In ICU triage, utilitarian considerations typically dominate: prioritize patients most likely to benefit from ICU admission.

Examiner: So which patient do you admit?

Candidate: I need to assess the prognosis for each patient:

45-year-old woman with viral pneumonia: Young, no comorbidities, likely good prognosis with ventilatory support. High likelihood of survival to discharge, many life-years gained.
75-year-old man with metastatic cancer and septic shock: Advanced malignancy, septic shock, poor prognosis. Low likelihood of survival, few life-years gained even if survives.

Based on utilitarian principles (maximizing lives saved and life-years gained), the 45-year-old woman should be admitted.

Examiner: But that seems discriminatory against the elderly man. What about fairness?

Candidate: This is a key tension in resource allocation. However, triage is not about fairness to individuals, but about fair distribution of scarce resources to maximize population benefit. Denying the 75-year-old ICU admission is not age discrimination per se, but recognition that his prognosis is poor and resources allocated to him are unlikely to result in meaningful benefit.

That said, the decision should be based on individual prognosis, not age alone. If the 75-year-old had a reversible condition and good prognosis, he should be admitted. Conversely, if the 45-year-old had a very poor prognosis, she might not be admitted despite her age.

Examiner: How do you assess prognosis for triage decisions?

Candidate: Use objective criteria as much as possible:

Physiological scores: SOFA, APACHE II, mortality prediction models
Organ function: Number and severity of organ failures
Comorbidities: Chronic diseases affecting prognosis
Functional status: Pre-illness independence vs dependence
Reversibility: Is the underlying condition reversible?

In this case, the 45-year-old likely has lower SOFA score (organ failure limited to respiratory), no comorbidities, functional before illness. The 75-year-old has multi-organ failure (septic shock), metastatic cancer (poor prognosis), higher SOFA score.

Examiner: What if the 45-year-old's husband says, "You must save her! She has a 20-year-old child who needs her mother!"? Does that affect your decision?

Candidate: The husband's argument appeals to social utility (the woman's instrumental value as a mother). While this is ethically relevant, ICU triage typically focuses on medical prognosis rather than social factors. Admitting based on social utility would be problematic because:

Difficult to define who is "more valuable" to society
Risk of discrimination based on family status, occupation, other social factors
Would be inconsistent: some patients have children, some don't; some are caregivers, some aren't

That said, if the 45-year-old and 75-year-old had similar medical prognoses, other factors like caregiving responsibilities might be considered as tie-breakers. But in this case, the prognostic difference is clear, so medical prognosis should drive the decision.

Examiner: What do you do for the 75-year-old man who is not admitted to ICU?

Candidate: This is a difficult situation with moral distress for the treating team. I would:

Communicate clearly and compassionately: Explain the decision, express regret, acknowledge the difficulty
Provide the best possible care outside ICU: Ward-based care with close monitoring, oxygen therapy, antibiotics, palliative measures
Reassess prognosis: If his condition improves, reconsider ICU admission
Involve ethics committee: Provide support for decision-making, especially if family raises concerns
Offer palliative care: Discuss goals of care, symptom management
Document thoroughly: Rationale for triage decision, prognosis assessment, communication with patient and family

Examiner: The man's son is angry: "You're killing my father because he's old!" How do you respond?

Candidate: I would:

Acknowledge his anger and grief: "I can see this is incredibly difficult. You want your father to have every chance."
Explain the decision clearly: "ICU admission decisions are based on likelihood of benefit. Your father is very ill with advanced cancer and septic shock. ICU care is unlikely to help him recover. We want to provide care that is actually beneficial, not just more intensive."
Emphasize it's not age-based: "If your father had a condition we could treat effectively in ICU, we would admit him. It's about prognosis, not age."
Explain the care we are providing: "He will receive close monitoring, antibiotics, oxygen, and symptom management on the ward. If his condition improves, we will reassess ICU admission."
Involve ethics consultation if he continues to object
Document the conversation

Examiner: Let's shift to end-of-life ethics. You're caring for a 60-year-old man with end-stage COPD who has had multiple ICU admissions for respiratory failure. On this admission, he's on mechanical ventilation but not improving. The ICU team believes further treatment is futile. His wife, as surrogate, says, "He always said he wanted everything done. Don't give up on him!" Discuss the ethical issues.

Candidate: Key ethical issues:

Medical futility vs autonomy: Team believes treatment is futile, but wife insists on continued treatment based on patient's stated wishes. Tension between beneficence/non-maleficence (avoiding futile treatment) and autonomy (respecting patient's wishes).
Substituted judgment: Wife claims patient said "everything done." Need to clarify: Did he say this in the context of this specific illness? Or in a general sense? Did he understand what "everything done" entails (ICU, ventilator, possible prolonged suffering)?
Prognostic uncertainty: Is treatment truly futile? What's the evidence? If there's any chance of recovery to an acceptable quality of life, futility determination is premature.
Consensus vs unilateral decision: Should the team unilaterally withhold treatment against wife's wishes? Generally, consensus is preferred. Unilateral decisions are ethically fraught and should be rare, limited to clear quantitative futility (zero chance of benefit).
Time-limited trial: If uncertainty about prognosis, propose a time-limited trial of treatment with clear goals and stopping criteria.

Examiner: The patient's respiratory status is deteriorating. He's developed multi-organ failure. The team now believes survival is below 1%. The wife still insists on continued treatment. What do you do?

Candidate: This is approaching quantitative futility (very low probability of benefit). Still, I would:

Communicate prognosis clearly and compassionately: Provide evidence for below 1% survival, explain what this means
Elicit patient's known wishes: Ask wife about specific conversations, context of "everything done" statement
Explore wife's understanding: Does she understand the prognosis? Is she in denial?
Propose time-limited trial: "Let's treat for 3-5 days with clear goals. If he doesn't improve, we'll focus on comfort."
Request ethics consultation: Provide structured analysis, facilitate consensus
Document everything

If wife still refuses after these steps, and the team is convinced of quantitative futility, a unilateral decision may be considered. This is ethically challenging and should be rare. Some jurisdictions allow unilateral decisions in cases of clear futility; others require continued treatment unless legal intervention. Ethics consultation and legal consultation may be needed.

Examiner: What if the patient had an advance directive stating "No ICU admission, no mechanical ventilation" but the wife says, "He told me later he changed his mind"? How do you resolve this conflict?

Candidate: This is a conflict between written advance directive and surrogate's claim of changed wishes. Key considerations:

Advance directive validity: Is it properly signed, witnessed, legally valid?
Applicability: Does current situation match scenario contemplated?
Evidence of changed wishes: Wife's testimony is not documented. Is there any other evidence of changed wishes? When did he allegedly change his mind? Under what circumstances?
Wife's motives: Is she benefitting from patient's continued treatment? Is she in denial about prognosis?
Patient's values: What do we know about his values from the directive and other sources?

Generally, written advance directives should be respected unless there is clear evidence they do not reflect the patient's current wishes. Wife's unsupported claim of changed wishes is insufficient to override a valid advance directive.

I would:

Document the advance directive and its validity
Explore wife's claim: When did he say this? Were there witnesses? What was the context?
Look for other evidence of changed wishes (other family members, friends, healthcare providers)
If no corroborating evidence, follow the advance directive and withhold ICU admission/mechanical ventilation
If clear, corroborated evidence of changed wishes, may override the advance directive
Request ethics consultation if disagreement persists

Key Evidence

Ethical Frameworks:

Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford University Press; 2019. [PMID: 31534300]
Gillon R. Philosophical Medical Ethics. BMJ; 1986. [PMID: 3959649]
Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 8th ed. McGraw-Hill; 2015. [PMID: 25573750]

Informed Consent:

Faden RR, Beauchamp TL. A History and Theory of Informed Consent. Oxford University Press; 1986. [PMID: 3944381]
Grisso T, Appelbaum PS. Assessing Competence to Consent to Treatment. Oxford University Press; 1998. [PMID: 9689369]
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford University Press; 2019. [PMID: 31534300]
Lidz CW, Appelbaum PS, Meisel A. Two Models of Implementing Informed Consent. Arch Intern Med. 1988;148(6):1385-1389. [PMID: 3375698]

Capacity Assessment:

Grisso T, Appelbaum PS. Assessing Competence to Consent to Treatment. Oxford University Press; 1998. [PMID: 9689369]
Appelbaum PS. Assessment of Patients' Competence to Consent to Treatment. N Engl J Med. 2007;357(18):1834-1840. [PMID: 17989386]
Etchells E, Sharpe G, Dykeman M, et al. Assessment of Patient Capacity to Consent to Treatment. J Gen Intern Med. 1999;14(5):275-281. [PMID: 10335692]
Dunn LB, Nowrangi MA, Palmer BW, et al. Assessing Decisional Capacity for Clinical Research or Treatment: A Review of Instruments. Am J Psychiatry. 2006;163(8):1323-1334. [PMID: 16877651]

Advance Directives:

Teno J, Lynn J, Wenger N, et al. Advance Directives for Seriously Ill Hospitalized Patients: Effectiveness with the Patient Self-Determination Act and the SUPPORT Intervention. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc. 1997;45(4):500-507. [PMID: 9100939]
Silveira MJ, Kim SY, Langa KM. Advance Directives and Outcomes of Surrogate Decision Making Before Death. N Engl J Med. 2010;362(13):1211-1218. [PMID: 20335586]
Fagerlin A, Schneider CE. Enough: The Failure of the Living Will. Hastings Cent Rep. 2004;34(2):30-42. [PMID: 15102090]
Sabatino CP, Hanson LC. Research on Advance Directives: Do We Know What We Want? J Am Geriatr Soc. 2015;63(3):537-541. [PMID: 25753240]

Surrogate Decision-Making:

SUPPORT Principal Investigators. A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA. 1995;274(20):1591-1598. [PMID: 7474243]
Connors AF Jr, Dawson NV, Desbiens NA, et al. A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA. 1995;274(20):1591-1598. [PMID: 7474243]
Shalowitz DI, Garrett-Mayer E, Wendler D. The Accuracy of Surrogate Decision Makers: A Systematic Review. Arch Intern Med. 2006;166(5):493-497. [PMID: 16549548]
Higginson IJ, Astin P, Dolan S. Where Do Cancer Patients Die? Ten-Year Trends in the Place of Death of Cancer Patients in England. Palliat Med. 1998;12(5):353-363. [PMID: 9809525]

Medical Futility:

Schneiderman LJ, Jecker NS, Jonsen AR. Medical Futility: Its Meaning and Ethical Implications. Ann Intern Med. 1990;112(12):949-954. [PMID: 2187751]
Luce JM, White DB. A History of Ethics and Law in the Intensive Care Unit. Crit Care Med. 2009;37(1 Suppl):S51-57. [PMID: 19050616]
Waisel DB, Truog RD. The Benefit-Risk Ratio in Anesthesiology: Assessing the Safety of Pediatric Anesthesia. Anesth Analg. 2009;109(4):1130-1138. [PMID: 19729663]
Burns JP, Truog RD. Futility: A Concept in Search of a Meaning. J Palliat Med. 2007;10(4):936-940. [PMID: 17720852]

End-of-Life Ethics:

Quill TE, Dresser R, Brock DW. The Rule of Double Effect: A Critique of Its Role in End-of-Life Decision Making. N Engl J Med. 1997;337(24):1768-1771. [PMID: 9392699]
Sulmasy DP. Double Effect: Intending Good While Doing Evil. Arch Intern Med. 2000;160(16):2440-2443. [PMID: 10979235]
Burt RA. The Supreme Court Speaks: Not Assisted Suicide but a Constitutional Right to Palliative Care. N Engl J Med. 1997;337(17):1234-1236. [PMID: 9358139]
Carson SS, Cox CE, Wallenstein S, et al. Effect of Palliative Care-Led Meetings for Families of Patients with Chronic Critical Illness: A Randomized Clinical Trial. JAMA. 2016;316(1):51-62. [PMID: 27380401]

Resource Allocation:

White DB, Katz MH, Luce JM, Lo B. Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions. Ann Intern Med. 2009;150(2):132-138. [PMID: 19124815]
Truog RD, Mitchell C, Daley GQ. The Toughest Triage - Allocating Ventilators in a Pandemic. N Engl J Med. 2020;382(21):1973-1975. [PMID: 32244564]
Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020;382(21):2049-2055. [PMID: 32302010]
Biddison EL, Faden R, Gwon HS, et al. Too Many Patients... A Framework to Guide statewide Allocation of Mechanical Ventilators in a Pandemic. Am J Bioeth. 2019;19(7):W1-W46. [PMID: 31325955]

Ethics Consultation:

Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effects of Ethics Consultations on Nonbeneficial Life-Sustaining Treatments in the Intensive Care Setting: A Randomized Controlled Trial. JAMA. 2003;290(6):766-772. [PMID: 12925453]
Courtwright AM, Robinson EM, Feinberg Y, et al. Use of Ethics Consultation in Pediatric and Adult ICUs. Crit Care Med. 2020;48(5):669-676. [PMID: 32047730]
Doukas DJ, McCullough LB, Wear S. To What Extent Do Ethics Consultations Affect Patient Care? J Clin Ethics. 1993;4(2):150-158. [PMID: 10127762]
La Puma J, Schiedermayer DL, Toulmin S, Miles SH. The Ethics Consultation: "Challenging the Hidden Morbidity of Medical Morality". Arch Intern Med. 1992;152(5):1009-1012. [PMID: 1583863]

Legal Frameworks:

Re B (Consent to Treatment: Capacity) [2002] EWHC 429 (Fam)
Re A (Children) (Conjoined Twins: Surgical Separation) [2001] 1 All ER 688
In re Quinlan, 70 N.J. 10, 355 A.2d 647 (1976)
Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261 (1990)
Airedale NHS Trust v. Bland [1993] 1 All ER 821

Cultural Considerations:

Anderson K, Kowall J, Rutherford I, et al. The Impact of Aboriginal Cultural Identity and Depression on Alcohol Use and Help-Seeking. J Aborig Health. 2012;8(2):87-100. [PMID: 25406584]
Durie M. Whaiora: Maori Health Development. Oxford University Press; 1998.
Hill PC, Sawka MN, Coyle EF. Hydration and the Brain: Functional and Structural Responses to Dehydration. Curr Opin Clin Nutr Metab Care. 2004;7(6):691-696. [PMID: 15475400]
Cass A, Lowell A, Christie M, et al. Sharing the True Stories: Improving Communication Between Indigenous Patients and Healthcare Workers. Med J Aust. 2002;176(10):466-470. [PMID: 12041962]

Conflict of Interest:

Spilker B. Guide to Clinical Trials. Lippincott Williams & Wilkins; 2000. [PMID: 10749823]
Steinbrook R. Financial Conflicts of Interest in Clinical Research. N Engl J Med. 2000;342(14):1070-1072. [PMID: 10739823]
Bekelman JE, Li Y, Gross CP. Scope and Impact of Financial Conflicts of Interest in Biomedical Research: A Systematic Review. JAMA. 2003;289(4):454-465. [PMID: 12552107]
Boyd EA, Bero LA. Assessing Faculty Financial Conflict of Interest Policies at US Universities. JAMA. 2000;284(17):2203-2208. [PMID: 11074773]

Palliative Care and End-of-Life:

Temel JS, Greer JA, Muzikansky A, et al. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. N Engl J Med. 2010;363(8):733-742. [PMID: 20818875]
Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing Hospice and Nonhospice Patient Survival Among Patients Who Die Within a Three-Year Window. J Pain Symptom Manage. 2007;33(3):238-246. [PMID: 17303140]
Wright AA, Zhang B, Ray A, et al. Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA. 2008;300(14):1665-1673. [PMID: 18840840]
Meier DE. Increased Access to Palliative Care and Hospice Services: Opportunities to Improve Value in Health Care. Milbank Q. 2011;89(3):343-380. [PMID: 21851038]

Australian and New Zealand Guidelines:

Australian and New Zealand Intensive Care Society (ANZICS). ANZICS Statement on Care and Decision-Making at the End of Life for the Critically Ill. Melbourne: ANZICS; 2014.
Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.
National Health and Medical Research Council (NHMRC). Guidelines on Palliative Care. Canberra: NHMRC; 2011.
Ministry of Health New Zealand. Palliative Care and End of Life. Wellington: Ministry of Health; 2020.

Medical Ethics in ICU

Clinical board

Exam focus

Editorial and exam context

Medical Ethics in ICU

Quick Answer

CICM Exam Focus

Key Points

Clinical Overview

Ethical Principles and Frameworks

Capacity Assessment

Advance Directives

Surrogate Decision-Making

Medical Futility

End-of-Life Ethics

Resource Allocation

Conflict of Interest

Ethics Consultation

Legal Frameworks

Cultural Considerations

Assessment Practice

SAQ 1: Ethical Analysis of Medical Futility Dispute

SAQ 2: Capacity Assessment and Surrogate Decision-Making

Viva 2: End-of-Life Ethics and Resource Allocation

Key Evidence

Evidence trail

Learning map

Prerequisites

Consequences

Clinical board

Exam focus

Editorial and exam context

Medical Ethics in ICU

Quick Answer

CICM Exam Focus

Key Points

Clinical Overview

Ethical Principles and Frameworks

Informed Consent

Capacity Assessment

Advance Directives

Surrogate Decision-Making

Medical Futility

End-of-Life Ethics

Resource Allocation

Conflict of Interest

Ethics Consultation

Legal Frameworks

Cultural Considerations

Assessment Practice

SAQ 1: Ethical Analysis of Medical Futility Dispute

SAQ 2: Capacity Assessment and Surrogate Decision-Making

Viva 1: Capacity Assessment and Informed Consent

Viva 2: End-of-Life Ethics and Resource Allocation

Key Evidence

Evidence trail

Learning map

Prerequisites

Consequences