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4.6. Ethical Issues identified in Intensive Care Units of a University Hospital

- Younsuck Koh*., Eun Yong Ku*2,
Young-Mo Koo*3, Ock-Joo KIM*5, 
Soon Haeng Lee*2, Sang Il Lee*4, Oh Su Han*3

Department of Internal Medicine*, Department of Nursing*2,
Department of Medical Humanities & Social Sciences*3,
Department of Preventive Medicine*4, Asan Medical Center,
University of Ulsan College of Medicine,
Department of Medical Education, College of Medicine,
Korea University*5, Seoul, Korea

Background

Physicians and nurses deal with medical decision-making, informed consent, withholding/withdrawing of life-sustaining therapy, resource allocation, and the quality of life in everyday intensive care. As intensive care medicine provides more advanced and complicated therapies to critically ill patients, it results in increase in medical cost, and admission of more seriously ill patients in intensive care units (ICUs). These situations are accompanied with the increase in complicated ethical issues and patients' expectations to modern medicine. Naturally, the appropriate communication between the patient and professional, in addition to professional competency, becomes more important for the good patient-physician relationship in ICUs. The healthcare system can also affect the healthcare providers' attitude for the intensive care, which requires continuous investment for the maintaining appropriate level of care.

The environment for critical care has been deteriorated compared with other fields of medicine in Korea. There is no formal specialty of critical care medicine in Korea. Furthermore, the shortage of fulltime critical care physicians and critical care nurses, and unreasonable reimbursement from the insurance agency for the critical care in Korea has been eroding quality of care in ICUs. Critical care nurses, thus, are expected to encounter frequent ethical problems during routine patient management in ICU. However, the ethical problems perceived by the nurses have largely unknown in Korea.

The aims of the study were to describe and assess nurses' perceptions of ethical issues in ICUs of a University hospital. The results of this study are directly applicable to improve the ethical environment in the subjected ICUs.

Methods

A daily prospective confidential questionnaire survey to critical care nurses was conducted by a research nurse at the medical, surgical, neurological, and neurosurgical intensive care units at Asan Medical Center from February 1 to October 30, 2002. The 27 topics of the questionnaire included demographic information, level of rapport between patient or patient's family with attending physician, level of therapeutic intervention, developed issues of medical ethics, person and date of identified, and reason to happen. The described topics of medical ethics in the questionnaire were informed consent, futile management, do not resuscitate (DNR) status, withdrawal/withholding of life sustaining treatment, the ethical issues related to therapeutic limitation due to medical insurance reimbursement, resource allocation, transportation of patient, rebate or presents from patient or his/her family or companies, organ transplantation, clinical research in ICU, unethical behavior or malpractice by healthcare provider, and others. We selected the topics referencing the ethical statements of Korean Society of Critical Care Medicine.

We educated the nurses of the 4 ICUs on the topics in the questionnaire for 2 hours before the initiation of the study. We asked them classify the observed issue to one of the described topics in the questionnaire on their judgments. They were also asked to describe the experienced issue briefly. Two of medical ethic specialists independently reviewed appropriateness of the reported issues with their description and reclassified the issues. The discrepancies between two reviewers reached the final classification by the reviewing the medical records and interview with the reported nurse if necessary.

The results are expressed as percent of incidence. Data were analyzed with SAS statistical program (SAS Institute Inc., version 6.12, Cary, NC, USA). Two-tailed Student's t-tests, and the Chi-square test were used to test the significance of differences in responses where appropriate. Differences were considered to be statistically significant if p-value is lower than 0.05. The institutional review board of Asan Medical Center approved this study.

Results

1) Demographic characteristics of the reported cases: Eighty-nine cases (80 patients) among 2,608 admitted cases in the ICUs (3.4%) were reported during the study period. Three times in 1 patient and 2 times in 7 patients were reported. Male patients comprised 61.8% (n=55). The mean age of the reported cases was 59.8 (} 17.9) years, which was significantly older than the unreported cases (52.8 } 17.9 years) (p <0.001). The mean ICU stay is also longer in the reported cases (60.1 days vs. 5.9 days) (p=0.054). Ninety-five percent of the reported patients were under respiratory failure when reported. The clinical conditions on the reported day were either improving (20 cases, 22.5%), or stationary (23 cases, 25.8%), or deteriorating (23 cases, 25.8%), or moribund (12 cases, 13.5%), or near fatal (7 cases, 7.9%), or vegetative (3 cases, 3.4%), or dead (1 case, 1.1%). Only 18 cases (20.2%) had clear mentality when reported. The decision of DNR was entered in 16 cases (18%). Among them, 7 cases were entered DNR state by the attending physicians with the family's permission within 7th day of ICU admission. The level of relationship between patient or patient's family and attending physician was more than ordinary in 91 % of the cases.

2) Difference in case report depending on the study period and places: Monthly reported cases were from 3 to 19 cases. Fifty-two cases were reported in the day duty time (from 8 a.m. to 3 p.m.) of nurses. Thirty-six cases (40.4%) from medical ICU (MICU), 17 cases (19.1%) from surgical ICU (SICU), 11 cases from neurological ICU (NRICU), and 25 cases from neurosurgical ICU (NSICU) were reported. Doctors developed 70 cases (78.7%) of the reported. Among them, residents cause 46 cases. Nurses were also involved in the 24 cases. The nurses worked in the ICUs less than 3 years gave rise to 12 of the 24 cases. Patient's family developed 5 cases of the reported.

3) Ethical issues of the reported cases: The reported medical issues by the observers were 6 of informed consent, 8 of futile management, 1 of DNR, 12 of life sustaining treatment withdrawal/withholding, 5 of resource allocation, 8 of patient's transportation, 1 of organ transportation, 2 of clinical study, 50 of unethical behavior, and 34 of others. The reclassified reported cases after the assessment by the reviewers were 21 of informed consent, 10 of futile management, 1 of DNR, 8 of life sustaining treatment withdrawal/withholding, 5 of resource allocation, 9 of patient's transportation, 1 of organ transportation, 3 of clinical study, 27 of unethical behavior, and 32 of others. The issue related with unethical behavior (50 vs. 27 cases) was the least concordant followed by informed consent (6 vs. 21 cases) between the observer and the reviewer.

Conclusion

The commonly developed ethical issues were related to unethical behavior of the caregivers and informed consent in ICUs, which can be improved by the planned ethical education to the caregivers.

The Asan Research Institute for Society and Medicine supported this study.

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