Ethical Considerations on the ICU
Dr John Griffiths DICM MRCP FRCA MA
Focus on advance directives
An advance directive, (also known as a “living will”) is a statement made by a competent adult about the way he/she wishes to be treated if, in the future, he or she becomes incompetent and therefore unable to make a valid choice as to treatment (Appendix 1). As competent adult patients have a right to refuse medical treatment, an advance directive is a way of prolonging autonomy. An advance directive cannot request treatment that is not in the best interests of the patient. Advance directives are recognised by the courts as legally binding - Re T (1992), Re C (1994).
Conditions for a valid advance directive:
- The advance directive is made by a competent adult (18 years old and over).
- It is entered into voluntarily - the individual was not coerced into making the statement.
- The individual is sufficiently informed about the medical prognosis if the advance refusal is respected.
It is applicable to the circumstances that arise.
Questions that a clinician or clinical ethics committee may need to consider:
- Does a patient have a valid advance directive?
- Is the advance directive applicable to the circumstances of the case?
- Is there any evidence that the patient has revoked the advance directive?
Where there is a real issue about the validity of an advance statement, given a particular clinical situation, the appropriate action is to take the course that preserves future choice for the patient.
Relevant professional guidance:
Withholding and withdrawing life-prolonging medical treatment: guidance for decision making. 2nd Edition, BMA, 2001
Section 10.2 states that, where time permits, enquiries should be made to clarify the patient's intentions, for example by speaking to those close to the patient and contacting his/her general practitioner.
"Where there are good grounds for genuine doubt about the validity of an advance refusal, there should be a presumption in favour of life and emergency treatment should be provided. Treatment may, however, be withdrawn at a later stage should the validity, or existence, of a valid advance directive become clear" (Section 10.2)
Withholding and withdrawing Life-prolonging Treatments: Good Practice in Decision-making, GMC, August 2002
".. doctors must respect any valid advance refusal of treatment - one made when the patient was competent - which is clearly applicable in the circumstances and where there is no reason to believe the patient has changed his/her mind". (paragraph 7)
Appendix 1. Extracts from a medical advance directive
"I declare that if at any time ... I have become unable to participate effectively in decisions about my medical care; and two independent physicians (one a consultant) are of the opinion that I am unlikely to recover from illness or impairment involving severe distress or incapacity for rational existence,
1. I am not to be subjected to any medical intervention or treatment aimed at prolonging or sustaining my life;
2. Any distressing symptoms ... are to be fully controlled by appropriate analgesic or other treatment, even though that treatment may shorten my life.
1 wish it to be understood that I fear degeneration and indignity far more than I fear death. I ask my medical attendants to bear this statement in mind when considering what my intentions would be in any uncertain situation. "
Key learning points
- An understanding of key ethical considerations is important for ICU practitioners
- Advance directives and surrogates are increasingly well recognised.
- ICU clinicians must neither take over nor repudiate responsibility in end-of-life decision-making
- End-of-life decisions should be individual to each patient
- The advice of ethics committees and relevant professional bodies may be necessary to guide the decision making process.
Advance directives are the solution to Dr Campbell's problem of voluntary euthanasia.
J Med Ethics 1999; 25: 245-246.
Advance statements about medical treatment - code of practice, BMA, April 1995
The Patients Association. Advance Statements about Future Medical Treatment. A Guide for Patients (1996)