Ethical Issues in the Cardiac Intensive Care Unit

Ethical challenges abound in intensive care units (ICUs). Treatment in ICUs represents one of the costliest and most aggressive forms of Western medicine. ICU patients are the sickest and the most unstable, and they often cannot participate in health care decision making. Patients' families and loved ones are often left reeling by the sudden onset of serious illness. These factors bring to the ICU a host of difficult and troubling ethical issues. Our societal discomfort with human mortality, combined with media that exaggerate what modern medicine can accomplish, can exacerbate the discord that often arises when engaging these ethical challenges. Responding in an informed, compassionate, and ethically supportable manner is an essential part of high-quality critical care medicine.

The primary defining characteristics of cardiac ICU (CICU) patients are cardiovascular instability and life-threatening illness that require intensive monitoring, advanced life-support techniques, or both. Many such patients have poor prognoses; a substantial percentage die without leaving the hospital. Hence clinicians working in critical care must be comfortable working in the presence of death and dying and must be prepared for the attendant ethical challenges that often arise. These issues include, but are not limited to, writing do-not-resuscitate (DNR) orders, negotiating with family members or surrogates who do not want a patient to be told about a terminal diagnosis or prognosis, trying to determine what level of treatment an irreversibly ill patient without decision-making capacity would choose if able, and withholding or withdrawing life support. As medicine's ability to preserve the physiologic functioning of critically ill patients has improved, physicians, other clinicians, patients, and their families are increasingly faced with questions of when and how to terminate life-sustaining treatment.

When addressing these issues, clinicians are best served by remembering that their primary responsibility is to act in the patient's best interest by maintaining open and honest communication with patients, their surrogates, and with each other. Acting in the patient's best interest means providing the high-quality treatment and care for those who will likely survive the CICU and facilitating a peaceful and dignified death for those who will not.

Economic and resource utilization issues complicate further the work of ICU professionals. In the United States, CICU beds cost from $4000 to $10,000 per day. In the current climate of increasing pressures to limit health care costs, the pattern of increased financial costs accrued by patients with poor prognoses in ICUs has drawn increased scrutiny, prompting the study of strategies to avoid prolonged futile ICU treatment. The practice of providing tens of thousands of dollars' worth of advanced care to ICU patients who have essentially no chance of recovery is ethically problematic, given the potential to deplete patients' savings and to drive them and their families into bankruptcy. Furthermore, health care resources are limited, in terms of dollars, ICU beds, and personnel time and effort. With many CICUs routinely filled to capacity, allowing patients with no real chance of improvement to occupy CICU beds may prevent other patients with a high probability of benefiting from intensive care from being able to gain access to the CICU. Although there is general opposition to withholding potentially beneficial therapies solely for economic reasons, in the current political and economic climate, critical care physicians and other clinicians should become conversant with ICU economics and develop sound stewardship practices of CICU resources.

This chapter provides a basic overview of the ethical challenges that arise in critical care medicine. After a review of basic principles, guidelines, and methods of bioethics, as well as a discussion of the ethical challenges related to health care economics in the ICU, this chapter focuses on specific ethical issues related to withholding and withdrawal of life support. Brief discussions of euthanasia and cross-cultural conflict are also included. Some cases are presented to illuminate how the frameworks and practices described in this chapter may be applied.

Western Bioethics

Bioethics addresses two distinct but overlapping areas: the generic issue of what it means to provide health care in a manner consistent with basic moral values and the more specific challenge of identifying principles and guidelines for proper conduct that can be widely agreed on by the health care professions. For example, although confidentiality in medicine, as in law, is a strict ethical rule, it derives less from abstract moral values and more from its necessity for the effective provision of treatment and care. For the purposes of this chapter, the term bioethics represents guidelines for proper and principled conduct by health care professionals.

Although Western bioethics dates to the ancient Greeks, it only started to develop into a discipline of its own in the 1950s, largely as a result of new dilemmas posed by powerful new medical therapies. As medicine developed and strengthened its ability to maintain physiologic functioning in the face of ever greater insult and injury to the human body, patients—and more often their surrogates, families, and health care professionals—found themselves struggling with a central question of when treatments are life sustaining versus death prolonging. The 1976 New Jersey Supreme Court decision in the case of Karen Ann Quinlan established that advanced life support could be withdrawn from patients who have essentially no chance to regain any reasonable quality of life. Since that time, many other legal decisions, state and federal laws, and reports and consensus statements from various professional societies and regulatory commissions have helped define in what manner, under what circumstances, and by whose authority advanced or basic life support can be forgone.

A variety of methods for “thinking ethically” have been identified and used during the decades-long evolution of the field of bioethics. We have selected three methods that have been the most influential in bioethical analysis to date and that are the most helpful for addressing clinical situations in the CICU. The three methods are (1) principlism, (2) consequentialism, and (3) casuistry. Clinicians should not feel compelled to choose one of these methods over the others as their primary way for ethical analysis and reflection. Instead, using some combination of the three methods in most cases can be the most helpful.

Principlism

Principlism holds that actions must be evaluated based on their inherent qualities and the motivations or intentions underlying the actions. When applied to the clinical setting, principlism asserts that clinicians have specific obligations, moral duties, and rules that, in most circumstances, should be followed and fulfilled. Beauchamp and Childress have identified four fundamental principles and duties from which all other bioethical principles and duties can be derived: patient autonomy, beneficence, nonmaleficence, and justice. However, it is impossible for clinicians to perform their duties without sometimes violating one or more of these fundamental principles. Indeed, many ethical dilemmas present a clash between these principles; in such situations, health care professionals must choose which principle to uphold and which to relinquish.

Patient Autonomy.

Autonomy refers to the fundamental common law right of patients to control their own bodies. As the U.S. Supreme Court ruled in 1891 in a case unrelated to health care: “No right is held more sacred or is more carefully guarded by the common law than the right of every individual to the possession and control of his own person, free from all restraints or interference by others, unless by clear and unquestionable authority of law.” In medical terms, patient autonomy means the right of self-determination, including the right to choose for oneself among various recommended therapies. Autonomy also implies a respect for adult patients capable of making their own decisions. The principle of autonomy stands in contrast to paternalism, which presumes that physicians and other health care professionals know best and decide for the patient or authoritatively direct patients to the “right decisions.” The delineation between respect for autonomy and paternalism can be captured by affirming that in the decision-making process, clinicians have a role to inform, educate, advise, recommend, guide, and even try to persuade patients but should never engage in manipulation or coercion.

Respect for autonomy means that adult patients with decision-making capacity have the right to refuse medical treatments even if the treatments are life sustaining. It follows that, except in emergency situations, patients must consent to any treatments they receive and they must understand the risks, benefits, and reasonable alternatives of any proposed therapies or procedures for this consent to be meaningful. Withholding information from patients is a threat to their autonomy.

The acuity of CICU patients' illnesses should not be used as an excuse for failing to obtain informed consent for treatment in general or for procedures in particular. Physicians have the responsibility to ensure that the health care provided is in accord with patient wishes. For patients lacking decision-making capacity, a patient-designated surrogate or a close family member should be identified to help plan an appropriate level of treatment consistent with the best available knowledge of what the patient would have wanted. Patients do not have the right to demand specific treatments; only licensed health care providers have the authority to determine which of the therapies under their purview are indicated for a patient.

Minors do not enjoy the same decisional rights as adults and are generally not viewed as sufficiently autonomous by law to make their own health care decisions. Instead, these decisions usually fall to the minor's parents or legal guardian. However, U.S. courts have consistently been willing to overrule parents in cases in which there is evidence that the parents' decisions are not consistent with the best interests of their child. For example, although adult Jehovah's Witnesses can refuse medically indicated blood transfusions for themselves, they cannot make the same refusal on behalf of their children.

Beneficence.

The principle of beneficence represents health care professionals' responsibility and ethical duty to benefit their patients. This duty encompasses the promotion of patients' health and well-being as well as reducing suffering when possible. At its most basic level, beneficence is necessary to justify the practice of medicine, because if professionals do not benefit their patients, there is no rationale for the work. One caution related to the principle of beneficence is that professionals may judge “patient benefit” primarily in physiologic categories related to medical goals and outcomes. However, from the patient's perspective, benefit may include not only medical outcomes but also psychosocial-spiritual outcomes, interests, and activities that help to define the meaningfulness and quality of a patient's life. Thus, a recommended intervention with the likelihood of a good medical outcome but which would not allow a patient to continue a significant interest or activity could be judged differently by the patient than by the health care team because of differing perceptions of “benefit.”

More philosophically, beneficence as a principle in medicine supports the sanctity of human life and asserts the significance of human experience. In this regard, health care professionals practice beneficence not only by curing diseases, saving lives or alleviating pain, nausea, and other discomforts but also by expressing empathy and kindness—by contributing to patients' experiences that they are cared for and that their suffering is recognized. In the CICU, with critically ill patients near the end of life, presence, compassion, and humanity are sometimes the greatest forms of care and benefit that clinicians can offer.

Nonmaleficence.

Nonmaleficence requires physicians and other clinicians to avoid harming patients. More colloquially cited as “first, do no harm,” the principle of nonmaleficence warns clinicians against overzealousness in the fight against disease. Unfortunately, opportunities to do harm in medicine abound. Almost every medication and procedure can cause adverse effects and simply being in the hospital and in the ICU puts patients at risk for blood clots and infection by a more dangerous group of microorganisms than they would likely encounter at home. Unnecessary tests may unearth harmless abnormalities, the work-up of which may result in significant complications. An unnecessary central venous line may result in a pneumothorax, bloodstream infection, or thrombus. Unnecessary antibiotics may result in anaphylactic shock, Stevens-Johnson syndrome, acute tubular necrosis, pseudomembranous colitis and toxic megacolon, or subsequent infection by resistant organisms. Many clinicians tend to feel much more comfortable with acting than with refraining from acting; hence, in the face of clinical uncertainty, many physicians are inclined to order another test or try another medication. It is essential that physicians constantly and consistently assess the potential benefits and the potential harms (including financial costs) that may result from each test and treatment they prescribe for each patient.

There are also other harms specific to the CICU. When patients languish on mechanical ventilation or invasive circulatory assistance without a reasonable possibility of recovery, physicians violate the principle of nonmaleficence. For many or most patients, the ICU can be an uncomfortable and undignified setting, filled with unfamiliar and jarring sights and sounds. Being sustained on mechanical ventilation ranges from unpleasant to miserable unless the patient is unconscious or heavily sedated. The only justification for putting patients through such experiences is an expectation that they have a likelihood of returning to some reasonable quality of life as determined by the patient's values. When physicians' care and treatments serve only to prolong the process of dying and suffering, they violate nonmaleficence.

Just as physicians can harm their patients by providing excessively aggressive treatments, they can also harm patients by withholding care from them. When patients remain in the CICU for prolonged periods of time or their disease and complications are particularly troubling, physicians may be inclined to spend less time with sicker persons or to focus on flow sheets and documentation rather than on these challenging patients. Illness, however, is often a lonely and frightening experience; abandonment by clinicians adds to patient suffering.

Justice.

Justice in clinical ethics means a fair allocation of health care resources, especially when the resources are limited. In the United States, on the macro-allocation level, there has been a failure to achieve a just health care system by any standard. The quality and accessibility of medical care available remains largely a function of an individual's socioeconomic status and racial/ethnic categorization. Americans in disadvantaged economic, ethnic, or racial groups receive less care, lower-quality care, suffer greater morbidity and mortality from illness, and die younger in most disease-specific categories than do other citizens. The principle of justice demands that health care resources be allocated not according to the ability to pay but rather according to need and to the potential of treatment to benefit the individual.

On a micro-allocation level, the principle of justice plays a role in the CICU in terms of triage. With a limited number of beds, those in charge of the unit must decide which patients have the greatest need and the greatest potential to benefit. Moreover, because intensive care represents a very expensive form of medical intervention, consuming over 13% of U.S. hospital costs and 4% of total U.S. health care expenditures, there is a strong national interest in curtailing wasteful ICU use. The concepts of futility and rationing help in analyzing the challenge of triage but, as Jecker and Schneiderman have observed, the two terms have different points of reference. Determinations of futility are related to whether identified goals of treatment are achievable. Further, futility can have two distinct meanings, referring either to treatment that has essentially no chance of achieving its immediate physiologic purpose or outcome or that has essentially no chance of meaningfully benefiting the patient. For example, treating a bacterial pneumonia in a brain-dead patient would be considered not futile with the former definition and certainly futile with the latter. The threshold for futility is a contentious subject; some have argued that the impossibility of arriving at widely accepted objective, quantitative standards renders use of the term inappropriate.

Futility differs conceptually from rationing in that futility applies to an individual patient's likelihood of benefiting from treatment, whereas rationing refers to the distribution of limited resources within a population. Rationing is fair only when it is applied in an even-handed way for patients with similar needs, without regard to race, ethnicity, educational level, or socioeconomic status. Futility affects triage decisions because futile treatment violates the principles of beneficence and nonmaleficence. Such wasteful use of medical care also violates the principle of justice when resources are limited. Rationing comes into play when there are more patients who need ICU care than there are beds, mechanical ventilators, or other critical care resources available. As health care costs continue to climb, physicians may find increasing pressures in the CICU to limit treatment for patients with poor prognoses. The ethical test in such circumstances is whether rationing is necessary and whether it is applied in a fair manner (i.e., whether similar cases are treated similarly). To maintain a clear understanding of what physicians are doing, it is essential that assertions of futility do not become either a mask behind which rationing or hospital cost-saving decisions can hide or a means of bullying patients or their families into accepting treatment-limitation decisions.

The four principles of bioethics can help untangle and clarify many complex and troubling dilemmas. In different cases, each of the individual principles may seem more or less important, but they are all usually pertinent in some way. These principles can certainly come into conflict with each other, which can then signify the presence of an ethical dilemma. Practically, the principles can help to pose a series of significant, patient-centered questions for clinicians: Am I respecting my patient's autonomy? Has the patient consented to the various treatments? Do I know my patient's resuscitation status? Is my therapeutic plan likely to benefit my patient? Am I doing all I can to improve my patient's well-being? Am I minimizing patient harm? Have I identified goals of treatment or care with my patient (or the surrogate) and are those goals achievable? Is there an appropriate balance between potential benefit and risk of harm? Is my plan of care consistent with the principle of justice?

Consequentialism

The second method for “thinking ethically” about clinical and ICU situations is consequentialism, which has its root meaning in the Western philosophical theory of teleology (“telos” in Greek means “ends”). Consequentialist reasoning judges actions as right or wrong based on their consequences or ends. This method of reasoning and analysis requires an anticipatory, projected calculation of the likely positive and negative results of different identified options prior to decisions and actions being carried out. For example, a physician may be requested by family members not to disclose a poor prognosis to their hospitalized loved one because, in their view, the disclosure will cause the patient to experience distress and to lose hope. Because the patient should be at the center of a “calculation of consequences” for this scenario, the first question should be this: How will the disclosure or nondisclosure impact the patient, both positively by way of benefits or negatively by way of harms? The patient is not the only one who will experience consequences as a result of this particular decision, however. Other stakeholders who can be affected positively and negatively include the patient's family members (will they be angry and feel betrayed if the poor prognosis is disclosed or will they ultimately feel relieved?), bedside nurses and other involved health care professionals (will they feel distress if they are expected to participate in a “conspiracy of silence” or if the patient asks them a direct question about the prognosis?), the hospital (will disclosure or nondisclosure be in accord with organizational values, such as respect for patients and compassion?), and even the wider community and society (how will other and future patients be affected if they come to know that physicians at this particular hospital disclose or do not disclose poor prognoses to patients?). When applying consequentialism, the projected and accumulated benefits and harms for all involved should be weighed against each other with the goal of maximizing benefits and minimizing harms.

One challenge of calculating consequences for the options in each medical situation is how to be sufficiently thorough in anticipating what the projected outcomes and results might be. For many situations, experienced physicians and other clinicians, using their knowledge of previous cases and building on their collective wisdom, can reasonably project medical, legal, and psychosocial-spiritual consequences for the different options. A more problematic challenge when using consequentialism is determining how much weight to assign each of the various beneficial and burdensome consequences. For example, should a potential legal risk to the physician and hospital that could result from a specific bedside decision be given more weight than doing what is clearly in a patient's best medical interests? In the end, after identifying and weighing projected burdens and benefits of reasonable options, clinicians using consequentialism would be ethically required to choose and act on the option that is likely to produce the most benefit and to avoid the option(s) likely to bring the most harm.

Casuistry

The third method of analysis that can lead to ethically supportable actions is casuistry, a word that shares its linguistic roots with the word “cases.” Although the term may not be familiar to many clinicians, the method itself is likely to be familiar to them. Casuistry is based on practical judgments about the similarities and differences between and among cases. Both medicine and law use this methodology when they look to previous and precedent cases to provide insight about a new case at hand. For example, when a patient presents to a physician with a specific set of symptoms and complaints and after the physician analyzes the results of various diagnostic tests, a skilled and knowledgeable physician is usually able to arrive at a specific diagnosis. The diagnosis is based on attention to the details of the patient's symptoms and test results but is also based on the physician's training and experience of having personally seen or having read in the published literature about similar or identical cases. Casuistry in ethical analysis uses a parallel kind of reasoning.

According to casuistry, attention must first be given to the specific details, features, and characteristics of the ethical dilemma at hand. Then, the goal is to identify known previous cases that are analogous to the new case and had reasonably good and ethically supportable outcomes. If such a previous or paradigm case can be identified for which a consensus exists about correct action, then this previous case can provide ethical guidance for the new case at hand. For example, a 25-year-old ICU patient with Down syndrome and an estimated cognitive ability of a 4-year-old is in need of blood transfusions. Her family members are Jehovah's Witnesses and adamantly object to the transfusions based on their religious beliefs. Using casuistry and appealing to similar cases, the ICU team notes that there is an ethical and legal consensus related to pediatric patients of Jehovah's Witness parents to override parental objections to blood transfusions and to act in the patient's best interests. Because the 25-year-old patient's cognitive ability is similar to that of pediatric patients who do not have the cognitive ability to commit themselves knowingly and voluntarily to a set of religious tenets, the ethically supportable option in the pediatric cases (i.e., overriding parental objections to blood transfusions) could be extended to this case.

An additional feature of casuistry is that as cases are compared and similarities and differences are identified, moral maxims or ethical rules of thumb can emerge that can also be helpful for current and future cases and dilemmas. Such moral maxims include adult, informed patients with decision-making capacity can refuse recommended treatment; a lesser harm to a patient can be tolerated to prevent a greater harm; and physicians are not obligated to offer or provide treatments that they judge to be medically inappropriate. One challenge of casuistry is to pay sufficient attention to the relevant facts and details of the new case to be able to identify previous cases that are similar enough to provide guidance for the case at hand.

An effective use of casuistry by physicians and health care teams can lead to the buildup of a collective wisdom and practical experience from which to draw when new ethical dilemmas arise. Parallel again to physicians building up medical experience and wisdom over time, physicians can establish an ethical storehouse of knowledge and insight based on previous cases and ethical dilemmas that they have experienced, heard about, or read about.

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