ACCCN's Critical Care Nursing

5 Ethical Issues in Critical Care





Amanda Rischbieth
Julie Benbenishty



paramount to critical care nurses (as part of the
Learning objectives critical care team), whose patient cohort is a particularly
vulnerable one. Critical care nurses are encouraged to
After reading this chapter, you should be able to: participate in discussion and educational opportunities
● understand the diversity and complexities of ethical issues regarding ethics in order to provide clarity in relation to
involving critical care practice fulfilment of their moral obligations. The need to support
● understand key ethical principles and how to apply them in critical care nurses, by mentoring for example, is very
everyday practice as a critical care registered nurse important in terms of developing moral knowledge and
3
● be aware of the availability and access to additional competence in the critical care context.
resource material that may inform and support complex Common ethical principles that relate to critical care
ethical decisions in clinical practice nursing practice are outlined in this chapter, with a
● discuss the ethical implications of the organ donation for description of how they may be applied to practical
transplantation decision-making process situations such as clinical decision making, obtaining
● understand consent and guardianship issues in critical care informed consent and applied research. Ethical implica-
● describe the ethical conduct of human research, in tions of brain death and organ donation that particularly
particular issues of patient risk, protection and privacy, and relate to nursing practice are also reviewed.
how to apply ethical principles within research practice.
PRINCIPLES, RIGHTS AND
THE LINK WITH LAW
Key words THE DISTINCTION BETWEEN
ETHICS AND MORALITY
futility
consent Ethics deal with all aspects of human behaviour and are
ethical decision making often complex and contentious. Many clinical scenarios
invite ethical reflection and raise questions about
organ donation health professionals’ decision making and behaviour, as
ethical principles distinct from specific diagnostic or technical questions.
patient advocacy In it simplest form, ethics refer to standards that govern
end-of-life behaviours.
Ethics involve principles and rules that guide and justify
conduct. Personal ethics may be described as a personal
INTRODUCTION set of moral values that an individual chooses to live by,
whereas professional ethics refer to agreed standards and
Nurses are expected to practise in an ethical manner,
through the demonstration of a range of ethical compe- behaviours expected of members of a particular profes-
2
tencies articulated by registering bodies and the relevant sional group. Bioethics is a broad subject that is con-
codes of ethics (see Boxes 5.1 and 5.2). It is important cerned with the moral issues raised by biological science
that nurses develop a ‘moral competence’ so that they are developments, including clinical practice.
able to contribute to discussion and implementation of Although some nurses draw a distinction between ethics
issues concerning ethics and human rights in the work- and morality, there is no philosophical difference between
1
place. Moral competence and ethical action is the ability the two terms, and attempting to make a distinction can
4
to recognise that an ethical issue exists in a given clinical cause confusion. Difficulties arise in ethical decision
situation, knowing when to take ethical action if and making where no consensus has developed or where all
when required, and a personal commitment to achieve the alternatives in a given situation have specific draw-
2
78 moral outcomes. This diverse understanding of ethics is backs. These types of situations are referred to as ‘ethical

Ethical Issues in Critical Care 79

refraining from obstructing their actions unless these are
BOX 5.1 Australian Nursing and Midwifery clearly detrimental to others or themselves. To show lack
Council Code of Ethics for Nurses in of respect for an autonomous agent, or to withhold infor-
Australia, June 2002 61 mation necessary to make a considered judgement, when
there are no compelling reasons to do so, is to repudiate
Value statements that person’s judgements. To deny a competent indivi-
1. Nurses respect individual’s needs, values, culture and vul- dual autonomy is to treat that person paternalistically.
nerability in the provision of nursing care. However, some persons are in need of extensive protec-
2. Nurses accept the rights of individuals to make informed tion, depending on the risk of harm and likely benefit of
choices in relation to their care. protecting them, and in these cases paternalism may be
3. Nurses promote and uphold the provision of quality nursing considered justifiable. 6,7
care for all people. According to the principle of autonomy, critical care
4. Nurses hold in confidence any information obtained in a patients are entitled to be treated as self-determining.
professional capacity, use professional judgement where Where the patient is incompetent, healthcare profession-
there is a need to share information for the therapeutic als ought to act so as to respect the autonomy of the indi-
benefit and safety of a person, and ensure that privacy is vidual as much as possible, for example by attempting to
safeguarded. discover what the patient’s preference would have been in
5. Nurses fulfil the accountability and responsibility inherent the current circumstances. (This requirement will be dis-
in their roles. cussed in detail in the section below on decision making.)
6. Nurses value environmental ethics and a social, economic
and ecologically sustainable environment that promotes Nurses are autonomous moral agents, and at times may
health and wellbeing. adopt a personal moral stance that makes participation
in certain interventions or procedures morally unaccept-
able (see the Conscientious objection section later in this
chapter).

Beneficence and Non-maleficence
BOX 5.2 Nursing Council of New Zealand The principle of beneficence requires that nurses act in
Code of Conduct for Nurses, December ways that promote the wellbeing of another person; this
2004 15 incorporates the two actions of doing no harm, and maxi-
mising possible benefits while minimising possible harms
Principles (non-maleficence). It also encompasses acts of kindness
8
1. The nurse complies with legislated requirements. that go beyond obligation. In practice this means that
2. The nurse acts ethically and maintains standards of although the caregiver’s treatment is aimed to ‘do no
practice. harm’, there may be times where to ‘maximise benefits’ for
3. The nurse respects the rights of patients/clients. positive health outcomes it is considered ethically justifi-
4. The nurse justifies public trust and confidence. able that the patient be exposed to a ‘higher risk of harm’
(albeit ‘minimised’ by the caregiver as much as possible).
For example, in the coronary care unit (CCU) a patient
may require a central venous catheter (CVC) to optimise
dilemmas’. Dilemmas are different from problems, fluid and drug therapy, but this is not without its own
because problems have potential solutions. 5 inherent risks (e.g. infection, pneumothorax on inser-
tion). Evidence-based protocols exist for caregivers/nurses
ETHICAL PRINCIPLES for both the safe insertion of a CVC and subsequent care,
Key ethical (moral) principles include autonomy, benefi- so as to minimise possible harms to the patient.
cence, non-maleficence, justice and paternalism. Other
related ethical concepts include integrity, best interests, Justice
informed consent and advance directives. All are appli- Justice may be defined as fair, equitable and appropriate
cable to critical care practice. Some of these principles treatment in light of what is due or owed to an individual.
and how they relate specifically to critical care nursing The fair, equitable and appropriate distribution of health
practice are discussed individually in this chapter. Others care, determined by justified rules or ‘norms’, is termed
are incorporated in broader issues, such as brain death distributive justice. There are various well-regarded theo-
6
and organ donation. ries of justice. In health care, egalitarian theories generally
Autonomy propose that people be provided with an equal distribu-
tion of particular goods or services. However, it is usually
Individuals should be treated as autonomous agents; and recognised that justice does not always require equal
individuals with diminished autonomy are entitled to sharing of all possible social benefits. In situations where
protection. An autonomous person is an individual there is not enough of a resource to be equally distrib-
capable of deliberation and action about personal uted, often guidelines or policies (e.g. ICU admission
goals. To respect autonomy is to give weight to autono- policies) may be developed in order to be as fair and
mous persons’ considered opinions and choices, while equitable as possible.

80 S C O P E O F C R I T I C A L C A R E

Conditions of scarcity and competition result in the pre- documents can be accessed via the New Zealand Ministry
dominant problems associated with distributive justice. of Health (www.hon.govt.nz).
For example, a shortage of intensive care beds may result
in critically ill patients having to ‘compete’, in some way, PATIENTS’ RIGHTS
for access to the ICU. Considerable debate exists regard-
ing ICU access/admission criteria, that may vary across Patients’ rights are a subcategory of human rights. ‘State-
institutions. Resource limitations can potentially be seen ments of patients’ rights’ relate to particular moral inter-
to negatively affect distributive justice if decisions about ests that a person might have in healthcare contexts, and
access are influenced by economic factors, as distinct hence require special protection when a person assumes
4
from clinical need. 9 the role of a patient. Institutional ‘position statements’
or ‘policies’ are useful to remind patients, laypersons and
ETHICS AND THE LAW health professionals that patients do have entitlements
and special interests that need to be respected. These
Ethics are quite distinct from legal law, although these do statements also emphasise to healthcare professionals
overlap in important ways. Moral rightness or wrongness that their relationships with patients are constrained ethi-
may be quite distinct from legal rightness or wrongness, cally and are bound by certain associated duties. In addi-
4
and although ethical decision making will always require tion, the World Federation of Critical Care Nurses has
consideration of the law, there may be disagreement published a Position Statement on the rights of the criti-
about the morality of some law. Much ethically-desirable cally ill patient (see Appendix A3).
nursing practice, such as confidentiality, respect for
persons and consent, is also legally required. 4,10 Nursing codes of ethics incorporate such an understand-
ing of patient’s rights. For example, codes relevant to
Every country has its own sources and structures of law. nurses have been developed by the Australian Nursing
The terms ‘legislation’ and ‘law’ are used to refer generi- and Midwifery Council (2002) and the International
61
cally to statutes, regulation and other legal instruments Council of Nurses (2002) (see Box 5.1). In addition, the
14
that may be the forms of law used in a particular country. Nursing Council of New Zealand has published a Code
Legal systems elaborate rights and responsibilities in a of Conduct for Nursing that incorporates ethical princi-
variety of ways. A general distinction can be made between ples (2004) (Box 5.2). These codes outline the generic
15
civil law jurisdictions, which codify their laws, and obligation of nurses to accept the rights of individuals,
common law systems, where judge-made law is not con- and to respect individuals’ needs, values, culture and vul-
solidated. In some countries, religion informs the law nerability in the provision of nursing care. The New
based on scriptures. Zealand Code particularly notes that nurses need to prac-
In Australia, there are three broad sources of law. These tise in a manner that is ‘culturally safe’ and that they
are: should practise in compliance with the Treaty of Wait-
angi. (See Chapter 8 for further details on cultural aspects
● constitutional law; of care.) Furthermore, the codes acknowledge that nurses
● statute law or legislation (i.e. Acts of Parliament); accept the rights of individuals to make informed choices
● common law (i.e. decisions of judges). about their treatment and care.
Statute law has particular relevance to ethics in the
critical care context. Examples of statute law in Australia Consent
include: In principle, any procedure that involves intentional
contact by a healthcare practitioner with the body of a
● Consent to Medical Treatment and Palliative Care Act patient is considered an invasion of the patient’s bodily
1995 (SA); integrity, and as such requires the patient’s consent. A
● Medical Treatment Act 1988 (Vic.); healthcare practitioner must not assume that a patient
● Natural Death Act 1988 (NT); provides a valid consent on the basis that the individual
● Medical Treatment Act 1994 (ACT).
16
has been admitted to a hospital. All treating staff (nurses,
Further details of these Australian Acts can be found in doctors, allied health etc) are required to facilitate discus-
the Relevant legislation section at the end of the chapter. sions about diagnosis, treatment options and care with
the patient, to enable the patient to provide informed
One example of how statute law is applied in practice consent. When specific treatment is to be undertaken by
17
regards consent for life-sustaining measures; the Consent a medical practitioner, the responsibility for obtaining
11
to Medical Treatment and Palliative Care Act 1995 (SA) consent rests with the medical practitioner; this respon-
states that:
sibility may not be delegated to a nurse. 16
… in the absence of an express direction by the patient or the Patients have the right, as autonomous individuals,
patient’s representative to the contrary, [the doctor is] under to discuss any concerns or raise questions, at any time,
no duty to use, or to continue to use, life sustaining measures with staff. Hospitals should provide detailed patient
… (S17 (2))
admission information, including information regarding
It should be noted that each Australian state and territory ‘patients’ rights and responsibilities’, that usually include
has differences in its Acts, which can cause confusion. The a broad explanation of the consent process within that
New Zealand Bill of Rights and the Health Act 1956 are institution. In many countries there is no distinction
currently under revision in New Zealand. 12,13 These between the obligation to obtain valid consent from the

Ethical Issues in Critical Care 81

patient and the overall duty of care that a practitioner has However, it is incumbent on all critical care nurses, as
in providing treatment to a patient. Obtaining consent is patient advocates within the critical care areas of
part of the overall duty of care. 11 ICU, CCU and the emergency department (ED), to be
aware of the potential impact and possible outcomes
In recent decades, research in the biomedical sciences has of therapies delivered in the critical care environment.
been increasingly located in settings outside of the global Safe delivery of those therapies is often the nurse’s respon-
north. Much of this research arises out of transnational sibility, which is distinct from the medical order issued
collaborations made up of sponsors in high income to commence the treatment.
countries (pharmaceutical industries, aid agencies, chari-
table trusts) and researchers and research subjects in low- An understanding of the principle of consent is necessary
to middle-income ones. Research may well be carried out for nurses practising in critical care. Because of the vulner-
in populations rendered vulnerable because of their low able nature of the critically ill individual, direct informed
levels of education and literacy, poverty and limited consent is often difficult, and surrogate consent may be
access to health care, and limited research governance. the only option, particularly in an emergency. Consent
The protections that medical and research ethics offer in may relate to healthcare treatment, participation in
these contexts tend to be modelled on a western tradition human research and/or use and disclosure of personal
in which individual informed consent is paramount and health information. Each of these types of consent has
are usually phrased in legal and technical requirements. differing requirements. 19
When science travels, so does its ethics. Yet, when cast Consent to treatment
against a wider backdrop of global health, economic
inequalities and cultural diversity, such models often A competent individual has the right to decline or accept
2,3
prove limited in effect and inadequate in their scope. healthcare treatment. This right is enshrined in common
Attempts to address both of these concerns have gener- law in Australia (with state to state differences), and in
ated a wide range of ‘capacity-building’ initiatives in the Code of Health and Disability Consumers’ Rights in
13,20
bioethics in developing and transitional countries. New Zealand (1996). It is the cornerstone of the legal
Organisations such as the Global Forum for Bioethics in administration of healthcare treatment. With the intro-
21
Research, the Forum for Ethical Review Committees in duction in the UK of the Human Rights Act there is
the Asia Pacific Region and the World Health Organiza- increasing public awareness of individual rights, and in
tion have sought to improve oversight of research pro- the medical setting people are encouraged to participate
jects, refine regulation and guidance, address cultural actively in decisions regarding their care. Doctors daily
variation, educate the public about research and make judgements regarding their patients’ competency to
strengthen ethical review committee structures according consent to medical investigation and treatment, and in
to internationally acknowledged ‘benchmarks’. 4,5 today’s litigious climate they must face the possibility
that, from time to time, these decisions will be examined
The guidelines from the Council for International Organi- critically in a court of law. Capacity fluctuates with both
zations of Medical Sciences (CIOMS) – a body established time and the complexity of the decision being made;
jointly by WHO and UNESCO – take the position that thus, sound decisions require careful assessment of indi-
research involving human subjects must not violate any vidual patients.
universally applicable ethical standards, but acknowledge Accounts of informed consent in medical ethics claim
that, in superficial aspects, the application of the ethical that it is valuable because it supports individual auto-
principles, e.g. in relation to individual autonomy and nomy yet there are distinct conceptions of individual
informed consent, needs to take account of cultural values, autonomy, and their ethical importance varies. Consent
while respecting absolutely the ethical standards. provides assurance that patients and others are neither

Related to this issue is that of the human rights of research deceived nor coerced. Some believe that the present
subjects, as well as of health professionals as researchers debates about the relative importance of generic and spe-
in a variety of sociocultural contexts, and the contribu- cific consent (particularly in the use of human tissues for
tion that international human rights instruments can research and in secondary studies) do not address this
make in the application of the general principles of ethics issue squarely, believing that since the point of consent
to research involving human subjects. The issue concerns procedures is to limit deception and coercion, they
largely, though not exclusively, two principles: respect for should be designed to give patients and others control
autonomy and protection of dependent or vulnerable over the amount of information they receive and the
22
persons and populations. opportunity to rescind consent already given. There is a
professional, legal and moral consensus about the clini-
In order to provide safe patient care, clear internal systems cal duty to obtain informed consent. Patients have cogni-
and processes are required within critical care areas, as tive and emotional limitations in understanding clinical
with any other healthcare service provision. Critical care information. Such problems pose practical problems for
nurses need to be aware of the relevant policies and pro- successfully obtaining informed consent. Better commu-
cedures to have an understanding of their individual obli- nication skills among clinicians and more effective edu-
gations and responsibilities. Primarily, it is the treating cational resources are required to solve these problems.
medical officer who is legally regarded as the only person Social and economic inequalities are important variables
able to inform the patient about any material risks associ- in understanding the practical difficulties in obtaining
ated with a clinical therapy or intervention. 18 informed consent. Shared decision making within

82 S C O P E O F C R I T I C A L C A R E

clinical care reveals a pronounced tension between three In many countries, if patients believe that clinicians have
competing factors: (1) Paternalistic conservatism about abused their right to make informed choices about their
disclosure of information to patients has been eroded by care, they can pursue a remedy in the civil courts for
moral arguments now largely accepted by the medical having been deliberately touched without their consent
profession; (2) While many patients may wish to be given (battery) or for having received insufficient information
information about available treatment options, many about risks (negligence). To avoid the accusation of
also appear to be cognitively and emotionally ill equipped battery, clinicians need to make clear what they are pro-
to understand and retain it; and (3) Even when patients posing to do and why ‘in broad terms’. With respect to
do understand information about potential treatment negligence, the amount of information about risks
options, they do not necessarily wish to make such required is that deemed by the court to be ‘reasonable’ in
choices themselves, preferring to leave final decisions in light of the choices that patients confront. 25
the hands of their clinicians. 23
If a person is assessed as not being competent, consent
Consent is considered valid when the following criteria must be sought from someone who has lawful authority
are fulfilled; consent must: to consent on his or her behalf. If the courts have
appointed a person to be a guardian for an incompetent
● be informed (the patient must understand the broad individual, then the guardian can provide consent
nature and effects of the proposed intervention and on behalf of that individual. However, even for formally-
the material risks it entails) appointed guardians, certain procedures are not
● be voluntarily given allowed and the consent of a guardianship authority is
● encompass the act to be performed required. If there is no guardianship order then, strictly
● be given by a person legally competent to do so.
speaking, consents for healthcare treatment may be given
For incompetent individuals, the situation is less clear only by the guardianship authority. Some states have leg-
and varies between jurisdictions. islated to allow this authority to be delegated to a ‘person
responsible’ or ‘statutory health authority’ without
To be competent, an individual must:
prior formal appointment. This person would usually be
● be able to comprehend and retain information a spouse, close relative or unpaid carer of the incompe-
● believe it (i.e. they must not be impervious to reason, tent individual. As with formally appointed guardians,
divorced from reality or incapable of judgement after the powers of a ‘person responsible’ are limited by
reflection) statute. 19
● be able to weigh that information up (i.e. consider the
effects of having or not having the treatment) Consent to research involving humans
● make a decision based on that ability.
Consent in human research is guided by a variety of dif-
Many jurisdictions around the world have legislation to ferent documents. In Australia this predominantly
cover the case of an adult who is incompetent to give includes the National Health and Medical Research
consent. The legislation varies as to what situations are Council (NHMRC) and the National Statement on Ethical
8
covered, but some common themes are apparent. Conduct in Human Research (2007); while in New
Zealand it is by the Health Research Council of New
In an emergency, healthcare treatment may be provided Zealand (HRCNZ), Guidelines on Ethics in Health
without the consent of any person, although ‘emergency’ Research and the HRCNZ Operational Standard for Ethics
has not routinely been formally defined. It should also Committee (OS). 26,27 In the UK guidance is provided
be noted that nurses must seek consent for all procedures by the General Medical Council. In the US there are
24
that involve ‘doing something’ to a patient (e.g. admini- required elements of written Institutional Review Board
stering an injection), and should be wary of relying on (IRB) procedures under Department of Health and
‘implied’ consent. Seeking consent in this type of every- Human Services (HHS) regulations for the protection of
day situation is less formal than obtaining consent for a human subjects and relevant Office for Human Research
surgical intervention, although it still represents ethically Protections (OHRP) Department of Health and Human
(and legally) prudent practice. Consent should never be Services ‘guidance’ regarding each required element.
implied, despite the fact that the patient is in a critical
17
care area. Obtaining consent generally involves explain- Although the specific detail varies between organisations
ing the procedure and seeking affirmation from the and jurisdictions, in general ‘consent to medical research
patient (or guardian/family), ensuring that there is under- documentation’ should include the following: 19
standing and agreement to the treatment. This principle ● A statement that the study involves research
is clearly articulated by the General Medical Council in ● An explanation of the purposes of the research
the UK with the following statement: ● The expected duration of the subject’s participation
● A description of the procedures to be followed
Successful relationships between doctors and patients depend on ● Identification of any procedures which are
trust. To establish that trust you must respect patients’ autonomy experimental
– their right to decide whether or not to undergo any medical ● A description of any reasonably foreseeable risks or
intervention … [They] must be given sufficient information, in discomforts to the subject
a way that they can understand, in order to enable them to ● A description of any benefits to the subject or to others
make informed decisions about their care. 24 which may reasonably be expected from the research

Ethical Issues in Critical Care 83

● A disclosure of appropriate alternative procedures or promises of added benefits, and fewer side effects, and
courses of treatment, if any, that might be advanta- are heralded by drug companies and journals across the
geous to the subject world. Combinations of these therapies in critical care
● A statement describing the extent, if any, to which units are part of everyday management of critically ill
confidentiality of records identifying the subject will patients. While technology is capable of maintaining
be maintained some of the vital functions of the body, it may be less
● For research involving more than minimal risk, an able to provide a cure. Managing the critically ill patient
explanation as to whether any compensation, and an in many cases represents a provision of supportive, rather
explanation as to whether any medical treatments are than curative, therapies. 29
available, if injury occurs and, if so, what they consist A common ethical dilemma found in critical care is related
of, or where further information may be obtained. to the opposing positions of ‘maintaining life at all costs’
● An explanation of whom to contact for answers to and ‘relieving suffering associated with prolonging life
pertinent questions about the research and research ineffectively’. Patients that would probably have previ-
subjects’ rights, and whom to contact in the event of ously died can now be maintained for prolonged periods
a research-related injury to the subject on life support systems, even if there is little or no chance
● A statement that participation is voluntary, refusal to of regaining a reasonable quality of life. Assessment of
participate will involve no penalty or loss of benefits their ‘post-critical illness’ quality of life is complex,
to which the subject is otherwise entitled, and the emotive and forms the basis of significant debate, com-
subject may discontinue participation at any time pounded by the nuances of each individual patient’s case.
without penalty or loss of benefits, to which the Hence, decisions regarding withdrawal and withholding
subject is otherwise entitled.
of life support treatment(s) are not made without sub-
Consent to conduct research involving unconscious indi- stantial consideration by the critical care team. 30
viduals (incompetent adults) in critical care is one of the
situations not comprehensively covered in most legisla-
tion (see also Ethics in research later in this chapter). WITHDRAWING/WITHHOLDING TREATMENT
The incidence of withholding and withdrawal of life
Consent to collection, use, disclosure of support from critically ill patients has increased to the
health information extent that these practices now precede over half the
31
It is important to distinguish between health information deaths in many ICUs, although the incidence in other
critical care areas has not been reported. Although there
use (internal to an organisation) and disclosure (external is a legal and moral presumption in favour of preserving
dissemination) (see also responsible practices in Ethics life, avoiding death should not always be the pre-eminent
19
in research section later in this chapter).
32
goal. The withholding or withdrawal of life support is
Application of Ethical Principles in considered ethically acceptable and clinically desirable if
the Care of the Critically Ill it reduces unnecessary patient suffering in patients whose
prognosis is considered hopeless (often referred to as
Critical care nurses should maintain awareness of the ‘futile’) and if it complies with the patient’s previously
ethical principles that apply to their clinical practice. The stated preferences. Life support includes the provision of
integration of ethical principles in everyday work practice any or all of ventilatory support, inotropic support for the
requires concordance with care delivery and ethical prin- cardiovascular system and haemodialysis, to critically
ciples. There is a risk that nurses may become socialised ill patients. Withholding/withdrawal of life support are
into a prevailing culture and associated thought pro- processes by which healthcare therapy or interventions
cesses, such as the particular work group on their shift, either are not given or are forgone, with the understand-
the unit where they are based, or the institution in which ing that the patient will most probably die from the
they are employed. Depending on the prevalent culture underlying disease. 33
at any one of these levels, nursing practice may be highly
ethical or less ethically justifiable. The ‘group think’ In Australia, when active treatment is withdrawn or with-
approach of ‘That’s how we’ve always done it’ requires held, legally the same principles apply. The Australian
critical reflection on what is the ethical or ‘right thing to and New Zealand Intensive Care Society (ANZICS)
28
do’. Clinical audits and other dedicated review systems recommends an ‘alternative care plan’ (comfort care) be
and processes are useful platforms for ethical discussion implemented with a focus on dignity and comfort. All
and debate between critical care colleagues. discussions should be recorded in the medical records
including the basis for the decision, who has been
END-OF-LIFE DECISION MAKING involved and the specifics of treatment(s) being withheld
34
or withdrawn. There are marked differences in the ‘fore-
With advances in technology in health care, it is possible going of life-sustaining treatments’ that occur between
more than ever before to restore, sustain and prolong life countries and in the patient level of care variation even
with the use of complex technology and associated thera- within the same country. What may be adopted legally
pies, such as mechanical ventilation, extracorporeal oxy- and ethically or morally in one country may not be
genation, intra-aortic balloon counterpulsation devices, acceptable in another. The withholding and withdrawing
haemodialysis and organ transplantation. In addition, of therapies is considered passive euthanasia and is
new medication treatment options contribute significant legal and accepted practice in terminally-ill ICU patients

84 S C O P E O F C R I T I C A L C A R E

in most of Europe, however in parts of Europe, life- stated objection from a family member, especially if the
sustaining treatments are withheld but not withdrawn as person has medical power of attorney (or equivalent), the
the withdrawal of therapies leading to death is consid- doctor must take this into consideration and respect the
ered illegal and unethical. In the Netherlands and rights of any patient’s legal representative. In that event,
Belgium, active life ending procedures are permitted and it is likely that withdrawal of treatment will not occur
performed with the specific intent of causing or hasten- until concordance is reached. (This is different in the case
38
ing a patient’s death. In the US 35-37 and Europe the of a person who is legally declared brain dead; see Brain
majority of doctors have withheld or withdrawn life- death section.) 34
sustaining treatments.
In the Ethicus study of 4248 patients who died or had
The majority of the community and doctors favour active limitations of treatments in 37 ICUs in 17 European
life-ending procedures for terminally-ill patients. 39,40 In countries, life support was limited in 73% of patients.
the Ethicatt study, questionnaires on end of life decision- Both withholding and withdrawing of life support was
making were given to 1899 doctors, nurses, patients who practised by the majority of European intensivists while
were in ICUs and family members of the patients in six active life ending procedures despite occurring in a few
European countries. Less than 10% of doctors and nurses cases remained rare. The ethics of withdrawal of treat-
38
would like their life prolonged by all available means, ment are discussed in detail in the ANZICS Statement on
compared to 40% of patients and 32% of families. When Withholding and Withdrawing Treatment. The NHMRC
34
asked where they would rather be if they had a terminal publication entitled Organ and Tissue Donation, After
illness with only a short time to live, more doctors and Death, for Transplantation: Guidelines for Ethical Practice for
nurses preferred being home or in a hospice and more Health Professionals provides further discussion of the
patients and families preferred being in an ICU. Differ- ethics of organ and tissue donation. 44
ences in responses were based on respondent’s country. 39,40
DECISION-MAKING PRINCIPLES
Diverse cultural, religious, philosophical, legal and pro-
fessional attitudes lead to great difference in attitudes and Despite significant advances in medical technology and
practices. Observational studies demonstrate that North therapeutics, approximately 20% of patients admitted
American health care workers consult families more often to ICUs do not survive and the majority of those die in
than do European workers, 39,41 and some seriously ill ICU after the forgoing of life-prolonging therapies (as
patients wish to participate in end of life decisions whilst opposed to after cardiopulmonary resuscitation). Lack of
others do not. 42 communication creates a potential for patients to under-
go burdensome and expensive treatments that they may
In most cases where there is doubt about the efficacy and not desire. Some doctors do not communicate with
appropriateness of a life-sustaining treatment, it may be patients or families or document decisions because of the
considered preferable to commence treatment, with an lack of clear laws for end-of-life practices and the fear of
option to review and cease treatment in particular cir- litigation. Many families want to be involved but some
cumstances after broad consultation. Inconsistency exists individual family members do not want to be involved
in decision making about when and how to withdraw in end-of-life decisions. Individuals commonly want
life-sustaining treatment, and the level of communication their family to decide for them, although the judgement
9
among staff and family. Documented guidelines for ces- of intensive care professionals concerning which treat-
sation of treatment are not necessarily common in clini- ment should be given may well differ from that of patients
cal practice, with disparate opinion a recognised concern and families.
in some cases. Dilemmas arise when there are disparate
views within the team as to what constitutes ‘futility’ and End-of-life decision making is usually very difficult and
with associated decisions regarding the next step or steps traumatic. Because of this difficulty, there is sometimes a
when a patient’s outlook is at its most grave. In a UK lack of consistency and objectivity in the initiation, con-
study that attempted to draft cessation of treatment tinuation and withdrawal of life-supporting treatment in
30
guidelines, nursing staff were concerned over legality, a critical care setting. Traditionally, a paternalistic
morality, ethics and their own professional accountabil- approach to decision making has dominated, but this
ity. Medical decisions to withdraw treatment were shown stance continues to be challenged as greater recognition
to vary between medical staff and among patients with is given to the personal autonomy of individual patients. 9
similar pathologies. 43
Decision making in the critical care setting is conducted
Because ethical positions are fundamentally based on an within, and is shaped by, a particular sociological context.
individual’s own beliefs and ethical perspective, it may be In any given decision-making situation, the participants
difficult to gain a consensus view on a complex clinical hold different presumptions about their roles in the
situation, such as withdrawal of treatment. While it is process, different frames of reference based on different
essential that all members of the critical care team be able levels of knowledge, and different amounts of relevant
45
to contribute and be heard, the final decision (and ulti- experience. Nurses, for example, may conform to the
mately legal accountability in Australia and New Zealand dominant culture in order to create opportunities to par-
for the act of withdrawal of therapy) rests with the treat- ticipate in decision making, and thereby may conform to
ing medical officer. However, the decision-making process the values and norms of medicine. Although the nursing
certainly must involve broad, detailed and documented role in critical care is pivotal to implementing clinical
consultation with family and team members. If there is decisions, it is sometimes unacknowledged and devalued.

Ethical Issues in Critical Care 85


Clinical deterioration/non-response to
treatment or patient’s desire to limit treatment





Patient preferences
Ethical principles Discussion Decision-making capacity?
Beneficence YES: Informed consent
Non-maleficence Assessment NO: Proxy consent
Autonomy • best interests
Justice • substituted judgment
• advance directives

Disclosure




Contextual features
Family members Quality of life
Laws Determined by patient
Administrative issues (subjective)
Cost of care Determined by others
Just allocation resources (objective)


FIGURE 5.1 The decision-making process.



Nurses appear at times unable to influence the decision- satisfaction or happiness, or the attainment of personal
making process. 46 informed desires or preferences. Conversely, objective
components refer to factors outside the individual, and
Some international literature reflects the different ethical
reasoning and decision-making frameworks extant tend to focus on the notion of ‘need’ rather than desires
between medical staff and nurses. In general, nurses focus (e.g. the level to which basic needs are met, such as avoid-
on aspects such as patient dignity, comfort and respect ing harm, and adequate nutrition and shelter).
for patients’ wishes, while medical staff tend to focus on
patients’ rights, justice and quality of life. Involvement Best Interests Principle
47
of the patient (where possible) and family in decision The best interests principle is a guiding principle for deci-
making is an important aspect of matching the care pro- sion making in health care, and is defined as acting in a
vided with preferences, expectations, values and circum- way that best promotes the good of the individual. This
stances (see Figure 5.1). 48
principle is referred to when one person makes a decision
Quality of Life on behalf of another person (e.g. when a doctor makes a
decision to cease life-sustaining treatment for a particular
Despite the importance placed on quality of life in terms patient). This situation particularly arises when the
of its influence in the decision-making process, it is dif- patient is incompetent and is therefore unable to partici-
ficult to articulate a common understanding of the pate in the decision-making process.
concept. Quality of life is often used as a means of justify-
ing a particular decision about treatment that results in The best interests principle relies on the decision makers
either cessation of life or continued life-sustaining treat- possessing and articulating an understanding or account
ment, and it tends to be expressed as if a shared under- of quality of life that is relevant to the patient in question,
standing exists. 4 particularly in making end-of-life decisions. Although
assumptions are commonly made that a shared under-
Often, quality of life is considered to consist of both standing of the concept of quality of life exists, it may be
subjective and objective components, based on the that the patient’s perspective on what gives his or her life
understanding that a person’s wellbeing is partly related meaning is quite different from that of other people. In
to both aspects; therefore, in any overall account of the addition, individual preferences may change over time.
quality of life of a person, consideration is given to both For example, John may have stated in the past that he
9
independent needs and personal preferences. Subjective would never want to live should he be confined to a
components refer to the experience of personal wheelchair; however, after an accident has rendered him

86 S C O P E O F C R I T I C A L C A R E

a quadriplegic his preference may well be different. decision maker), or some combination of both. Advance
Ethical justification of the best interests principle there- directives can therefore inform health professionals how
fore requires a relevant and current understanding of decisions are to be made, in addition to who is to make
what quality of life means to the particular patient of them. New Zealand and most states of Australia have an
concern. 49 Act that allows for the appointment of a person to hold
52
enduring power of attorney. It is found in the literature
Patient Advocacy that most individuals do not want to write advanced
directives and are hesitant to document their end of life
Terms such as ‘medical agent’, ‘medical power of attorney’
and ‘enduring guardian’ are relatively common in rela- care desires. Advance directives were created in response
53,54
tion to patient advocacy. A medical agent is someone to increasing medical technology.
chosen by an individual (e.g. a partner, child, good friend An advance health care directive, also known as a living
who must be over 18 years) to make medical decisions will, personal directive, advance directive or advance deci-
on behalf of that person in the situation where the indi- sion, are instructions given by individuals specifying what
vidual becomes incompetent (i.e. when an individual actions should be taken for their health in the event that
lacks decisional capacity). Although it is possible to have they are no longer able to make decisions due to illness
a number of medical agents, only one may act for an or incapacity, and appoints a person to make such deci-
individual at one time. The medical agent should be sions on their behalf. A living will is one form of advance
someone not involved in a professional capacity in the directive, leaving instructions for treatment. Another
delivery of the related health care. For those who are not form authorises a specific type of power of attorney or
competent and require someone to be appointed to make health care proxy, where someone is appointed by the
healthcare decisions on their behalf, there are various individual to make decisions on their behalf when they
agencies such as ‘Guardianship Boards’ or ‘Office of the are incapacitated. People may also have a combination
Public Advocate’ – depending again on the specific juris- of both. One example of a combination document is the
diction – that will appoint such a person. Five Wishes advance directive in the US, created by the
non-profit organisation Aging with Dignity. Although
55
Enduring guardians can potentially make a wider range
of decisions than a medical agent, but an enduring guard- not legal documents, ‘good palliative care plans’ are used
ian can make decisions only once a person is considered in some jurisdictions as a record of a discussion between
to be unable to make his/her own decisions. Acts such as the patient, family members and a doctor about palliative
the Consent to Medical Treatment and Palliative Care Act care or active treatment. These are useful records to
1995 (SA) exist to facilitate choice in healthcare treatment provide clarity when treatment options require full and
that individuals may wish to have or refuse when they frank discussion and consideration, particularly regard-
are unable to make their wishes known because of an ing complex, critically ill patients (see Palliative care
illness. 11 below).
Substituted Judgement Principle Medical Futility
A substituted judgement is where an ‘appropriate surro- The concept of futility may be used by critical care doctors
gate attempts to determine what the patient would have and nurses as a rationale for why treatment, including
50
wanted in his/her present circumstances’. The person life-saving or sustaining treatment, is not considered to
making the decision should therefore attempt to utilise be in the patient’s best interests. At times, the concept of
the values and preferences of the patient, implying that futility may be used inappropriately, and therefore uneth-
the proxy decision maker would need an in-depth knowl- ically, for example if used to coerce relatives into agreeing
56
edge of the patient’s values to do so. Making a substituted to cease the patient’s treatment.
judgement is relatively informal, in the sense that the Futility is a concept that has widespread use in healthcare
patient usually has not formally appointed the proxy ethics guidelines for the cessation of treatment, particu-
decision maker. Rather, the role of proxy tends to be larly with reference to ‘do-not-resuscitate’ orders and the
assumed on the basis of an existing relationship between withdrawal of lifesaving or sustaining treatment. Treat-
proxy and patient. Difficulties related to this principle ment is considered futile if it merely preserves permanent
include that making an accurate substituted judgement is unconsciousness or cannot end dependence on intensive
50
very difficult, and that the proxy might not be the most health care. Futility is used to cover both cases of pre-
appropriate person to have taken on the role. 51 dicted impossibility of the success of treatment (‘physio-
logical’ futility) and cases in which there are competing
Advance Directives interpretations of probabilities and value judgements,
such as a balance of probable benefits and burdens. 6
For individuals wanting to document their preferences
regarding future healthcare decisions with the onset of Physiological futility is also commonly defined as ‘useless
incompetence, there are ‘anticipatory direction’ and treatment’; when clinicians conclude (through personal
‘advance directive’ forms available. Advance directives can experience, experience shared with colleagues, or consid-
be signed only by a competent person (before the onset eration of reported empirical data) that in the past 100
57
of incompetence), and can be either instructional (e.g. a cases a healthcare treatment has had no desired effect.
living will) or proxy (the appointment of a person(s) This particular definition is purported to defend against
with enduring power of attorney to act as surrogate doctors being pressured into pursuing extreme and

Ethical Issues in Critical Care 87

absurd interventions as a result of not being able to claim discussion of autopsy, and immediate bereavement
categorically that a particular treatment will be useless. support. A goal of mastering the palliative skills necessary
The proposal is justified by appealing to the commonly to competently care for an actively dying patient is to
used statistical evaluation employed in clinical trials (P = enable a patient to die peacefully and as free of as much
0.01). A physiologically futile treatment may be, for discomfort as possible. Guiding and supporting family
example, cardiopulmonary resuscitation in the setting members during this time takes significant courage,
where the patient has a ruptured left ventricle. strength and fortitude from critical care nurses as they
maintain their duties of care in physical, psychological
There is no definition of futility in Australasian legisla-
tion, although there is limited guidance within some and spiritual ways.
Acts. An example is provided by the South Australian
11
legislation referred to earlier : Euthanasia
Euthanasia, while being the subject of ongoing debate
[…] under no duty to use, or to continue to use, life sustaining across the globe over many years, remains illegal in Aus-
measures in treating the patient if the effect of doing so would tralia and New Zealand. Euthanasia is the termination of
be merely to prolong life in a moribund state without any real a very sick person’s life in order to relieve them of their
prospect of recovery or in a persistent vegetative state. (s17(2))
suffering. In most cases euthanasia is carried out because
the person who dies asks for it. Confusion has occurred
Do-not-resuscitate Considerations with some individuals unable to distinguish between the
in Critical Care process of withholding and withdrawing treatment and
Patients with acute, reversible illness conditions should that of euthanasia. The primary distinction relates to the
have the prerogative of resuscitation. Cardiopulmonary issue of ‘intent’. If the primary intention of the interven-
resuscitation (CPR) may be instigated in order to restore tion (e.g. a lethal injection) is to cause death, this may be
ventilation and circulation in patients, providing they do regarded as euthanasia and may be tested in court.
not have an irreversible or terminal illness. The decision However, if the primary intention of an act is to reduce
to withhold CPR may be termed a do-not-resuscitate pain and suffering, this may not be regarded as euthana-
(DNR) order in some jurisdictions. This reflects a deci- sia but may again be tested legally. The fact that the dif-
sion against any further proactive treatment such as CPR, ference between the two is complex and contentious adds
although there may be some limitations, such as ‘for to the vigorous debate by those ‘for’ and ‘opposed to’
defibrillation only’. Because each case must be considered euthanasia: an ongoing question for many years in many
on its merits, it is important to have clearly written countries. Religious opponents of euthanasia believe in
medical orders/directives so that misinterpretations do the sanctity of life and that life is given by God. Other
not occur. Paramount in these cases is clear discussion, opponents fear that if euthanasia was made legal, the
broad consultation and accurate documentation that laws regulating it would be abused, and people would be
reflects discussion between family and members of the killed who did not really want to die. Euthanasia is illegal
critical care team and any subsequent decisions. Any in most countries. Those in favour of euthanasia argue
directives must be clear to all those involved in the that a civilised society should allow people to die in
patient’s care. A management plan that incorporates dignity and without pain, and should allow others to
assessment, disclosure, discussion and consensus build- help them to do so if they cannot manage it on their own.
ing with the patient and family may be particularly The Netherlands legalised euthanasia, including doctor-
useful. 58 assisted suicide, in 2002. The law codified a twenty-year-
old convention of not prosecuting doctors who had
committed euthanasia in very specific cases, under very
Palliative Care in Critical Care specific circumstances. At times a patient may be influ-
59
Palliative care in the critical care unit occurs when a deci- enced to request the cessation of treatment as a conse-
sion has been made and documented to limit, withhold quence of unrelieved and enduring pain and suffering,
or withdraw treatment. Once it is evident that the patient’s and/or depression. In these circumstances, where such a
prognosis is grave and death likely to be imminent (albeit request may be thought to be inappropriate, it is proper
at times unpredictable in timing), it is the bedside critical to explore the patient’s feelings and treatment options
care nurse who becomes the leader in care provision for and perhaps to develop an agreed future treatment plan.
both the patient and their loved ones. It may be useful to obtain assistance from a counsellor
or other qualified professional. 58
Concepts in caring for the dying patient in a critical care
unit are no different from those in a hospital ward or
hospice. Privacy, dignity, a noise-free environment with Nursing Advocacy
minimal disturbance, relief of pain, provision of comfort, A commonly accepted view of nursing advocacy is where
support for both the patient and relatives, and coordina- the nurse is portrayed as helping the patient discuss his
tion of bedside visits are just a few key concepts, as is or her needs and preferences, helping the patient make
sensitive discussion (at the appropriate time) regarding congruent choices, supporting the patient’s decision, and
arrangements, wishes, belongings and cultural con- preventing others from impinging on the autonomy of
60
siderations after the patient’s death. Care does not end the patient. This view of nursing advocacy is reflected
with the death of the patient but continues through by the Australian Code of Ethics for Nurses: specifically,
death pronouncement, family notification of the death, nurses should ensure that patients are appropriately

88 S C O P E O F C R I T I C A L C A R E

informed to make choices about their treatment and to death will have occurred some indeterminate time before
maintain optimal self-determination (Value statement this but is only determined at this point. 62
61
2.3). One of the nurse’s roles is to initiate discussions
with patients and families to get a true understanding Brain death cannot be determined without evidence of
of the cultural beliefs regarding end-of-life care. When sufficient intracranial pathology. Cases have been reported
the information is collected the health care team can in which the brainstem has been the primary site of
collaboratively assist the patient and family to make injury and death of the brainstem has occurred without
appropriate decisions. Building trusting relationships is death of the cerebral hemispheres (e.g. in patients with
the objective. severe Guillain–Barré syndrome or isolated brainstem
63
injury). Thus brain death cannot be determined when
While most patients and surrogates agree with reasonable the condition causing coma and loss of all brainstem
healthcare recommendations to forgo life-sustaining function has affected only the brainstem, and there is still
therapy, there are times when members of either the blood flow to the supratentorial part of the brain. Whole
healthcare team or the patient’s family do not concur. brain death is required for the legal determination of
When disagreement or dissent occurs, it is prudent to death in Australia and New Zealand. This contrasts with
allow time to reconsider all elements in detail and to the UK where brainstem death (even in the presence of
proceed with caution and sensitivity. Collective agree- cerebral blood flow) is the standard. Brain death is deter-
ment should be the goal.
mined by clinical testing if preconditions are met; or
imaging that demonstrates the absence of intracranial
Conscientious Objection blood flow. The overall function of the whole brain is
In Australia nurses are empowered by the Australian Code assessed. However, no clinical or imaging tests can estab-
63
61
of Ethics to refuse to participate in any procedure that lish that every brain cell has died. According to the US
would violate their reasoned moral conscience (i.e. Uniform Determination of Death Act, brain death occurs
56
strongly held moral beliefs). In doing so, they must when a person permanently stops breathing, the heart
ensure that quality of care and patient safety are not stops beating and ‘all functions of the entire brain, includ-
compromised. In the critical care setting, such beliefs may ing the brain stem’ cease. Yet determining brain death is
impose on a nurse’s ability to care for a patient, in the a complex process that requires dozens of tests to make
case where the patient (or the patient’s family) has chosen sure doctors come to the correct conclusion. With that
to withdraw treatment, should the nurse hold strong goal in mind, the American Academy of Neurology issued
moral beliefs about the sanctity of human life. new guidelines in 2010 – an update of guidelines first
written 15 years ago, that call on doctors to conduct a
lengthy examination, including following a step-by-step
BRAIN DEATH checklist of some 25 tests and criteria that must be met
64
before a person can be considered brain dead. The goal
Brain death occurs in the setting of a severe brain injury of the guidelines is to remove some of the guess work and
associated with marked elevation of intracranial pressure. variability among doctors in their procedure for declaring
Inadequate perfusion pressure results in a cycle of cere- brain death, that previous research has found to be a
bral ischaemia and oedema and further increases in intra- problem, and were developed based on a review of all of
cranial pressure. When intracranial pressure reaches or the studies on brain death published between 1995 and
exceeds systemic blood pressure, intracranial blood flow 2009. According to the guidelines, there are three major
ceases and the whole brain, including the brainstem, signs of brain death: coma with a known cause; absence
62
dies. Determination of brain death requires that there of brain stem reflexes; and breathing has permanently
is unresponsive coma, the absence of brainstem reflexes stopped. Periodically, news reports will talk about a
and the absence of respiratory centre function, in the patient in a long-term coma that miraculously woke up,
clinical setting in which these findings are irreversible. In or someone in a persistent vegetative state who seems to
particular, there must be definite clinical or neuro-imaging have an inner life; one of the best known examples was
evidence of acute brain pathology (e.g. traumatic brain the Terri Schiavo case in Florida USA, which pitted the
injury, intracranial haemorrhage, hypoxic encephalopa- woman’s parents against her husband. The 41-year-old
thy) consistent with the irreversible loss of neurological Schiavo died in 2005, two weeks after the removal of a
function. 62
feeding tube that had kept her alive for more than a
ANZICS recommends clearly that whenever death is decade. But brain death should not be confused with
determined using the brain death criteria, it is certified by other conditions, such as persistent vegetative or mini-
two medical practitioners as defined by local legislation; mally conscious state, in which there is still some limited
consistent with the original intent of the Australian Law brain activity.
Reform Commission that the determination of brain
death should have general application, whether or not In a survey of 89 countries, legal standards on organ
organ and tissue donation and subsequent transplanta- transplantation were present in 55 of 80 countries (69%).
tion were to follow. Consistent with this, they also rec- Practice guidelines for brain death for adults were
62
ommend that the time of death is recorded as the time present in 70 of 80 countries (88%). More than one
when the second clinical examination to determine brain doctor was required to declare brain death in half of the
death has been completed. That is, when the process for practice guidelines. Countries with guidelines all specifi-
determination of brain death is finalised, recognising that cally specified exclusion of confounders, irreversible

Ethical Issues in Critical Care 89

coma, absent motor response, and absent brainstem even longer: for example, in the case of a pregnant
reflexes. Apnoea testing, using a PCO 2 target, was recom- woman, so that the fetus can reach viable independent
mended in 59% of the surveyed countries. This reflected existence.
uniform agreement on the neurologic examination with Donation of organs and tissues after death takes place
the exception of the apnoea test, however, it found other within a legal context. All states and territories of Austra-
major differences in the procedures for diagnosing brain lia, and New Zealand, provide a legislative basis for the
65
death in adults and recommended standardisation. removal of organs and tissues after death for the purpose
Organ donation provides the only hope for some patients of transplantation. In most of these jurisdictions, but not
awaiting a new heart, lung or liver. It also improves the Western Australia or New Zealand, death is defined
quality of life for patients on dialysis, and it restores sight in law.
to injured or blind patients. For an organ to be donated
in Australia or New Zealand, the process involves certifi- The Australian and New Zealand Human Tissue Acts pro-
cation of death, lack of objection from the deceased/ hibit trading in human organs or tissue. There are many
senior available next-of-kin, consent of the coroner (if countries including Australia and New Zealand that
applicable), and permission of the designated officer of believes that:
the hospital (see Chapter 27). Certification of brain death
is pivotal and inextricably linked to the organ donation ● no person, organisation or company should profit
and transplant process, as it allows the retrieval of well- financially from organ or tissue donation
perfused organs in good condition from patients who ● neither the estate of an organ or tissue donor nor his
have already been certified dead (namely the ‘beating- or her family should incur any cost from the processes
heart donor’). Diagnosis of brain death must be unequiv- that occur to facilitate organ and tissue donation.
ocal, thorough and transparent, so that it is regarded by
family and healthcare team as an absolute diagnosis Transplantation is an important part of modern medicine
without question. 66 and, in some cases, the only treatment for a range of
conditions.
Death requires documentation from a legal and social
position, although advances in modern technology have Important medical innovations have transformed the
blurred the distinction between life and death. The pro- outcomes for patients and aided the work of doctors. For
gression to development of specific brain death criteria example, clinical and critical care procedures have been
was to ensure unequivocal concordance in its diagnosis. improved and better anti-rejection drugs introduced. In
Brain death is established by documentation of irrevers- the UK, the NHS Organ Donation Report 2008–09 reports
ible coma, loss of brainstem reflexes and respiratory that while 90% of the UK population says that they
centre function, or by the demonstration of cessation of support organ donation, only 27% have joined the NHS
intracranial blood flow (see Chapter 27). Organ Donor Register.
ANZICS recommends that death be determined to have People who donate following brain death remain the
occurred when all of the following features are present: ‘gold standard’ for organ donation. They are the only
source of viable hearts after death and are able to provide
● immobility much better livers for transplantation. Notably, the
● apnoea increase in donation after cardiac death (DCD) is helping
● absent skin perfusion to increase the numbers of kidneys available for trans-
● absence of circulation as evidenced by absent arterial plantation substantially. However, the limitations of this
pulsatility for a minimum of two minutes, as mea- potential donor source need to be recognised alongside
sured by feeling the pulse or, preferably, by monitor- the complexities and sensitivities of the process. In
ing the intra-arterial pressure. Australia a national DCD Protocol, led by the
When all of these criteria have been met, the patient is National Health and Medical Research Council, has
66
determined to be dead and therefore organ removal may been progressed.
proceed. 62 There are four guidelines developed by the National
Health and Medical Research Council (NHMRC) of Aus-
ORGAN DONATION tralia that are useful resources for critical care clinicians
to consider:
According to ANZICS, dying is a process rather than an
event. The determination and certification of death 1. Organ and Tissue Donation by Living Donors: Guide-
62
indicate that an irrevocable point in the dying process has lines for Ethical Practice for Health Professionals:
been reached, not that the process has ended. Determina- outlines ethical practice for health professionals
tion of death by any means does not guarantee that all involved in living organ and tissue donation and
bodily functions and cellular activity, including that of provides guidance on how these principles can be
brain cells, have ceased. Several tissues can be retrieved put into practice. 67
for transplantation long after death has been determined 2. Living Organ and Tissue Donation: Guidelines for
by cessation of circulation. Similarly, after death has been Ethical Practice for Health Professionals: aims to help
determined by loss of whole brain function, the circula- people think through some ethical issues and
tion can be maintained for hours or days to enable organs make decisions about living organ and tissue
to be retrieved. Maintaining the circulation can continue donation. 68

90 S C O P E O F C R I T I C A L C A R E

3. Organ and Tissue Donation After Death, for Trans- Some distrust about brain death is evident in numerous
plantation: Guidelines for Ethical Practice for Health countries. One Australian study showed that 20% of fam-
Professionals: outlines ethical principles for health ilies of brain-dead patients continued to harbour doubts
professionals involved in donation after death and about whether the patient was actually dead, and a further
provide guidance on how these principles can be 66% of relatives accepted the death, but felt emotionally
71
put into practice. 69 that the patient was still alive. Researchers describe the
4. Making a Decision about Organ and Tissue Donation contradictions and ambiguities associated with caring for
after Death: this booklet is derived from Organ brain dead patients, particularly the ambiguity that
and Tissue Donation after Death, for Transplantation: accompanies caring for a brain dead body that exhibits
Guidelines for Ethical Practice for Health Professionals, traditionally accepted signs of life. 72,73
and aims to help people think through some
ethical issues and make informed decisions about In a recent Australian study of experienced intensive care
organ and tissue donation after death. 68 nurses, almost half the participants did not regard brain
74
death as a state of complete death. Further, there were
no correlations between brain death perception and the
DONATION AFTER CARDIAC DEATH independent variables of religious affiliation, intensive
There is increasing recognition of the role of donation care experience, experience of nursing brain dead patients,
after cardiac death (DCD) activity in Australia, New knowledge of brain death diagnostic procedures, educa-
Zealand and globally. So-called ‘cardiac death’ includes tional background, and knowledge of Australian legal
death of the person as a whole, with death of the brain definitions of death. Participants who were non-accepting
being an inevitable consequence of permanent cessation or ambivalent may not have perceived that the medico-
of the circulation. The organ yield (i.e. number of organs legal construct of brain death was congruent with their
74
usefully transplanted) may be less in a DCD donor than ‘personal foundational death notions’. Consequently,
that of a brain death donor due to the differences in the authors cautioned against equating lack of acceptance
timing and length of ‘warm ischaemic’ time. See also with a lack of knowledge of the clinical aspects of brain
Chapter 27. death, but rather suggested that for some nurses, the
concept of brain death may run counter to their
previously-formed concept of death. It is important that
NURSES’ ATTITUDES TO, AND KNOWLEDGE critical care nurses possess a thorough understanding of
OF, ORGAN DONATION brain death, and that they reflect on their personal con-
Some critical care nurses have dedicated roles in the ceptions about death.
organ donation team and may be integral in providing
knowledge and leadership in all aspects of donation and The ambiguity surrounding brain death is probably best
high-quality care in the end-of-life care process. They demonstrated by the common situation in an ICU, where
offer the option of donation as appropriate to families some staff may continue to talk to a patient (while pro-
and supporting their decisions at extremely sad and viding direct care) who has been diagnosed as brain dead.
stressful times. Communication and interpersonal skills This can cause confusion for relatives who have already
are essential. Trustworthy relationships maximise identi- been informed that the patient ‘is brain dead with no
fication and referral. 55 possibility of recovery or being able to comprehend/hear’.
An alternative view is that relatives may in fact be com-
Organ donation must be conducted in a manner that forted by staff ‘talking’ to their loved ones (albeit they are
is ethically and legally justifiable. Current legislation brain dead) until their final farewell. There is no defini-
and consistent hospital practices provide this framework tive right and wrong, but this dilemma reinforces the
in Australia and New Zealand. However, for some need for sensitivity by all staff in these cases.
staff working in an ICU the issue of organ donation is
vexed. It seems that for some individuals the notion of The issue of language used is also relevant to doctors and
brain death runs counter to personal beliefs formed nurses, with the use of the depersonalising terms ‘cadaver’
over many years (prior to intensive care unit exposure) and ‘harvesting’ perhaps serving to psychologically protect
about death. Personal beliefs or conceptions of death staff but perhaps acting as a barrier to effective commu-
75
may be informed by particular religions or other belief nication and understanding. The use of such language
systems. may reinforce the conceptual gap described above
between a personal notion of death and brain death.
The issue of organ donation also poses personal ethical
challenges for some individuals, perhaps related to beliefs Intensive care nurses are in a good position to foster a
held about the integrity of the human body and the positive attitude towards organ donation through educa-
interests of the donor and recipient. Some literature sug- tional and supportive actions with the family of the
gests that the current understanding of brain death is patient. It is recognised as important to allow the family
flawed, in that the diagnosis may be confused with ‘pro- time to come to terms with the death of the patient before
70
found coma associated with massive brain damage’, making their decision about donation. It may be useful
while acknowledging that it seems apparent that inade- to note that the majority of donor families say that they
quate brain death testing, or misapplication of brain would make the same choice again if given the opportu-
76
death criteria, is likely to be related to a wrong nity. Further discussion of the organ consent, donation
diagnosis. and transplant processes is provided in Chapter 27.

Ethical Issues in Critical Care 91

The role of the nurse in the organ donation process of a potential donor. Australian doctors would not
includes supporting the relatives, offering explanation proceed with organ donation without this agreement
and support, in addition to specific therapy delivery in an which is necessary for legal, ethical and medical reasons.
operational sense. In some ICUs, nurses participate in Ensuring family members understand each other’s wishes
seeking consent from relatives for organ donation, a task regarding organ and tissue donation, and improving
77
that has been shown to be very stressful. This stress arises consent rates at the time of request is fundamental to
from the perception that the intrusion may inflate the improving donation rates. Equally important is adequate
distress of the family. However, consenting to organ dona- training of health professionals to sympathetically and
tion in itself does not hinder or prolong the grief process. 78 sensitively approach the grieving family with full knowl-
edge of the process. 66
Research from the USA has noted a significant positive
correlation between higher knowledge levels possessed The experience of several comparable countries demon-
by intensive care nurses and more positive attitudes strates that a coordinated and integrated national
79
towards organ donation. In addition, nurses in the UK approach followed by sustained effort will over time see
who were found to hold positive attitudes to organ dona- real improvements in organ donation and transplanta-
tion were more likely to broach and discuss the possibil- tion rates. For example in Spain, the world leader in
80
ity of organ donation with families. However, acceptance organ donation, a central agency drives and coordinates
of the principle of organ donation among ICU nurses was a nationally consistent approach to clinical systems and
higher than support for donation of their own organs or practices and to community awareness and professional
those of a family member. This difference was attributed education; hospitals and their staff have sufficient train-
79
to some nurses not internalising the particular personal ing and capacity to identify all potential donors; and
values, attitudes and interests related to the concept of there are no cost barriers in hospitals that prevent organ
organ donation, therefore not being able to act on their donation proceeding.
beliefs.

This paradox may be reflected in the general public, as an
Australian study found that, while surveys of the general BOX 5.3 The Intruder
public continue to show considerable support for organ In 2009, Francine Wynn explored a philosophical reflection
donation programs, in practice donation rates continue written by John-Luc Nancy on surviving his own heart trans-
81
to be low. In the USA, of those people who state that plant. In The Intruder, Luc raises central questions concerning
they support organ donation, only about half actually the relations between what he refers to as a ‘proper’ life, that is,
consent to donate. 76
a life that is thought to be one’s own singular ‘lived experience’,
Organ donation occurs at a time of great emotional dis- and medical techniques. Nancy describes the temporal nature
tress. The terminology and phraseology in this section are of an ever-increasing sense of strangeness and fragmentation
necessarily factual, and might appear unsympathetic to which accompanies his heart transplant and opens up the
those most closely affected by organ donation. This dis- concept of transplantation in terms of the problematic ‘gift’ of
passionate reporting of events and outcomes should not a ‘foreign’ organ, the unremitting suffering intrusiveness of the
be taken as disrespectful to deceased donors or their fami- treatment regimen, and the living of life as ‘bare life’. Nancy
lies, or to the amazing gift that they make. 55 offers no answer to this dilemma, but instead calls on others to
think about the meaning or ‘sense’ of the prolonging of life and
Australia was a world leader in clinical outcomes for deferring of death. 55
transplant patients in 2010, and over 30,000 Australians
have benefited since transplantation first became a stan-
dard treatment option. More than ninety per cent of Aus-
55
tralians support organ donation. Despite this, Australia The mechanism of consent is proposed as one factor that
has a low rate of donation and consequently a new influences organ donation rates, with many European
national authority, The Australian Organ and Tissue countries using ‘opt-out’ consent processes. In contrast to
Authority (AOTA) was established in Australia in 2009 this, the NHS Organ Donation Taskforce published its
with the mandate to significantly improve organ and second report, The potential impact of an opt out system for
tissue donation and transplantation and to move Austra- organ donation in the UK, in November 2008 with the
lia from a low rate of donation to a leading country conclusion that ‘an opt out system is not right for the UK
performer. This national reform package was based on a at present’, but that the progress of the implementation
World’s Best Practice approach and plan, learning from program should be monitored to see whether the issue
leading country performers such as Spain, France, needs revisiting in future.
Belgium, Austria and the USA. Awareness and engage-
ment of the community, non-government sectors, donor ETHICS IN RESEARCH
families, and others involved in increasing organ and
tissue donation, is paramount with a national approach Respect for ethical codes is a requirement for all those
to in-hospital systems, resources and education of the conducting human research. There are various ethical
community and clinicians. 68 guidelines. For example, the Declaration of Helsinki is
regarded as authoritative in human research ethics. In the
In Australia, organ and tissue donation only occurs UK, the General Medical Council provides clear overall
with the agreement of the next of kin following the death modern guidance in the form of its Good Medical

92 S C O P E O F C R I T I C A L C A R E

Practice Statement. Other organisations, such as the APPLICATION OF ETHICAL PRINCIPLES
Medical Protection Society in the UK and a number of When considering human clinical research in the context
university departments, are often consulted by British of critical care, the concept of respect for persons is linked
doctors regarding issues relating to ethics. With respect to to the ethical principle of autonomy. In human research,
8
the expected composition of such bodies in the USA, respect for persons demands that participants receive
Europe and Australia, the following applies: USA recom- adequate information and enter voluntarily without coer-
mendations suggest that Research and Ethical Boards cion. Surrogate consent may be applicable in critical care
(REBs) should have five or more members, including at areas when research activities are being considered.
85
least one scientist, one non-scientist and one person not Other important and relevant ethical principles for
affiliated with the institution. The REB should include researchers are beneficence and non-maleficence.
people knowledgeable in the law and standards of prac- Beneficence in the research context is expressed by the
tice and professional conduct. Special memberships are researcher’s responsibility to minimise the risk of harm
advocated for handicapped or disabled concerns, if or discomfort to any research participants. Research pro-
8
required by the protocol under review. The European tocols should be designed to ensure that respect for
Forum for Good Clinical Practice (EFGCP) suggests that dignity and wellbeing takes precedence over expected
REBs include two practising doctors who share experience knowledge benefits. With regard to justice in research, this
in biomedical research and are independent from the requires that within a population there is a fair distribu-
institution where the research is conducted; one lay tion of ‘benefits and burdens’ for research participation,
person; one lawyer; and one paramedical professional, although the proportion of these will vary depending on
82
e.g. nurse or pharmacist. Healthcare research in Austra- the research activity.
lia is performed in accordance with guidelines issued by
the NHMRC, while in New Zealand the guidelines are When recruiting research participants it is important to
issued by the Health Research Council (HRC). Both ensure that any initial approach is made appropriately.
Councils have statutory authority, and health service and When the study involves recruitment of hospital inpa-
university Human Research Ethics Committees (HRECs) tients, this approach should be made by someone directly
(Australia) and both Health and Disability Ethics Com- involved in their care, with the aim of seeking permission
mittees and Institutional Ethics Committees (IECs) (New to then be approached by the investigators specifically
Zealand) are bound to consider research proposals in about the research. If the study involves recruitment of
accordance with the relevant recommended processes individuals from the community, this can be done by
and procedures outlined below. In subsequent discussion public display (e.g. flyers, published advertisements),
the above committees in both countries are referred to as providing the contact details of the researcher. Control of
ethics committees (ECs) for clarity, and operate in accor- involvement is then with the participant to make contact
dance with the following: with the researcher. While these processes may be inter-
preted as reducing or slowing recruitment, the principles
● The NHMRC National Statement on Ethical Conduct in of respect and autonomy for persons are upheld as the
Human Research 2007, is aimed primarily at research- potential for coercive recruitment is reduced. Another
ers, and provides a summary of principles. 8 guiding value in ethical research is that of integrity. This
● The NHMRC Human Research Ethics Handbook 2001 value requires that the researcher be committed to the
expands these principles, offers commentary and legal search for knowledge and to the principles of ethical
discussion, and is aimed at both HREC members and research, conduct and results dissemination. 8
researchers. 83
● The NHMRC Values and Ethics: Guidance for Ethical HUMAN RESEARCH ETHICS COMMITTEES
Conduct in Aboriginal and Torres Strait Islander Health
Research provides guidance to researchers, HRECs and Human Research Ethics Committees (HRECs) play a
Aboriginal-specific HRECs or subcommittees on the central role in the international system of ethical supervi-
conception, design and conduct of research involving sion of research involving humans. HRECs review pro-
84
Aboriginal and Torres Strait Islanders. It has the posals for research involving humans to ensure that the
same status as the National Statement. The documents research is soundly designed, and is conducted according
are to be used together. to high ethical standards such as those articulated in
● The New Zealand Operational Standard for Ethics Com- Australia in the National Statement on Ethical Conduct
12
mittee (OS) provides guidance on principles that in Human Research 2007 (known as the National State-
should be considered when reviewing research ment). Many other countries have similar systems and
proposals. statements or guidelines. While HRECs primarily fulfil a
● In addition, the HRC Guidelines on Ethics in Health guardian role, an often overlooked secondary purpose set
Research expands on the above standards and should out in the preamble to the National Statement is to ‘facili-
be used in combination (both documents are avail- tate research that is, or will be, of benefit to the research-
8
able online, see Online resources). er’s community or to humankind’. Thus HRECs are seen
● Individual Institutional/Hospital Research Ethics as having a role in promoting good research and good
Committees (IECs/HRECs) and Regional Ethics Com- ethical practice, as well as guarding against poor research
mittees have their own requirements for research pro- and poor ethical practice.
tocol ethics submission, compliance, monitoring and For a series of useful case studies related to complex and
complaints handling. challenging research governance debate, refer to NHMRC’s

Ethical Issues in Critical Care 93

Challenging Ethical Issues in Contemporary Research on Some hospitals have established multidisciplinary ethics
Human Beings 2006. 86 committees to provide a closed forum for clinicians to
raise ethical and legal concerns associated with particular
Research proposals involving human participants must
be reviewed and approved by a formally constituted EC treatments or decisions. These are distinct from the
that is established by, and advises, an institution or research ethics committees that examine the ethical
organisation regarding ethical approval for research pro- implications and recommend safeguards for research
jects. An EC must ensure that it is sufficiently informed projects. They are advisory and do not tell the clinicians
on all aspects of submitted research proposals, and is what to do, but do make recommendations. These con-
charged with the responsibility to ensure that investiga- sultations or meetings have yet to routinely include
tors undertaking human research are adequately knowl- patients in the discussions, but must take into account
edgeable and skilled in the research question and patients’ wishes. In addition to providing clinicians with
associated methodology. Additional expertise may be advice on particular cases these committees may also
sought either from individuals or from specific dedicated assist with the development of organisational policies on
‘shared assessment scheme’ groups as considered patient care and facilitate staff and patient education
necessary. 19 about ethical issues.
Presentation in person to HRECs in Australia is not
18
common but may be requested for complex protocols. PRIVACY AND CONFIDENTIALITY
In New Zealand, presentation in person to the IEC, while Privacy is a fundamental human right recognised in all
not compulsory, is common practice and highly recom- major international treaties and agreements on human
mended, as it often provides additional clarification. rights. Nearly every country in the world recognises
privacy as a fundamental human right in their constitu-
EC members have legal responsibilities in the following tion, either explicitly or implicitly. Most recently drafted
broad areas in relation to research subjects, researchers constitutions include specific rights to access and control
and their institutions: one’s personal information. New technologies are increas-
● negligence ingly eroding privacy rights. These include video surveil-
● breach of natural justice lance cameras, identity cards and genetic databases. There
● privacy is a growing trend towards the enactment of comprehen-
● breach of commercial confidentiality sive privacy and data protection acts around the world.
● defamation. Currently over 40 countries and jurisdictions have or are
87
in the process of enacting such laws. Countries are
CLINICAL ETHICS adopting these laws in many cases to address past
governmental abuses (such as in former Eastern Bloc
Clinical ethics relate to the moral and ethical issues and/
or conflicts that arise in everyday clinical practice. Ethical countries), to promote electronic commerce, or to ensure
dilemmas are hence a fact of life for healthcare clinicians compatibility with international standards developed by
and may involve any combination of patients, carers, the the European Union, the Council of Europe, and the
treating team, and family members. Healthcare services Organization for Economic Cooperation and Develop-
are delivered by individuals who hold a wide variety of ment. Surveillance authority is regularly abused, even in
beliefs and values with patients treated from a wide many of the most democratic countries. The main targets
variety of social, economic and cultural backgrounds and are political opposition, journalists and human rights
of different ages and capacity. activists. The US government is leading efforts to further
relax legal and technical barriers to electronic surveil-
Patients and healthcare workers bring their own life lance. The Internet is coming under increased
experiences as well as their own cultural, religious and surveillance. 88
linguistic backgrounds to their healthcare bedside set-
tings. Clinicians should provide care to all who need it Privacy legislation is described in the Privacy Act 1993
that respects, honours and supports cultural diversity. (with subsequent amendments in 1997, 1998, 2000,
Cultural competence describes the knowledge, skills and 2002, 2003 and 2005) in New Zealand and the Common-
attitudes that a healthcare worker needs to provide ade- wealth Privacy Act 1988 in Australia. While these two
quate and appropriate healthcare services to all people in pieces of legislation have many common features, they
this way. also have a number of differences, and their principles
are described below.
Within the clinical ethics remit, it is important to:
The Privacy Act 1993 is based on a series of 12 informa-
1. Organise and use interpreters appropriately. tion privacy principles (IPPs) (in Section 6) that outline
2. Create care environments that facilitate optimal the purpose, source, collection, access, storage, disclosure
patient and family control of decisions. and use of information throughout New Zealand. In
3. Work collaboratively with other healthcare workers addition the Act contains various codes of practice that
in a culturally sensitive and competent manner. relate to the use of information, and provides detail
4. Identify and address bias, prejudice and discrimi- regarding exemptions from the IPPs. Of note, the Act also
nation in healthcare service delivery. details (in Sections 12 – 25) the establishment and opera-
5. Integrate measures of patient satisfaction into tion of a Privacy Commissioner (see Online resources for
improvement programs. website address). The purpose of the Commissioner is to

94 S C O P E O F C R I T I C A L C A R E

oversee the implementation of the IPPs, including in edu- without consent only if the Chief Executive of the
cation and compliance issues. state health department considers it in the public
interest.
The Commonwealth Privacy Act 1988 sets out (in
Section 14) 11 IPPs that govern the conduct of Australian ● South Australia: In SA, a Cabinet instruction, based on
Commonwealth agencies in their collection, manage- federal IPPs, governs use and disclosure. That instruc-
89
ment and use of data containing personal information. tion does not permit relaxation of those standards,
The IPPs describe that agencies are not permitted to use although the Privacy Committee may exempt the hos-
or disclose, in identifiable form, records of personal pital, on conditions, from the requirements. There is
information for research and statistical purposes, unless also the Department of Health Code of Fair Information
specifically authorised or required by another law, or Practice 2004.
unless the individual has consented to their use or dis- ● Western Australia: The proposal for use and disclosure
closure (Privacy Act 1988). To avoid breaches of the above of personal information is reviewed by the Confiden-
privacy legislation where access to health information tiality of Health Information Committee.
may be required for research purposes, the NHMRC ● New South Wales: Both the Privacy and Personal Infor-
issued Guidelines under Section 95 of the Privacy Act 1988 mation Protection Act 1998 (NSW) and the Health
(s95 Guidelines). These were developed to provide a Records and Information Privacy Act 2002 (NSW) apply.
framework for the conduct of medical research where Directions under the former Act permitted relaxation
identifiable information held by any Commonwealth of its limits on disclosure. The latter Act permits dis-
agency (e.g. a public hospital) needs to be used without closure if the information is reasonably necessary for
consent, i.e. ‘if the public interest in the promotion of the research, if either the purpose cannot be achieved with
research is of a kind that outweighs “to a substantial non-identifying information or steps are taken to
degree” the public interest in maintaining adherence to de-identify the information, if results are not pub-
the IPPs’. 90 lished in a form that identifies individuals and if there
is an HREC review that favourably determines the
These were followed by the Guidelines approved under balance of public interests.
Section 95A of the Privacy Act 1988 (s95A Guidelines) to
provide a similar framework (to the s95); broadened to If the research is conducted at a national level and health
90
encompass the private sector. These include ten national information is needed from public and private hospitals
privacy principles (NPPs) that set the minimum stan- in all states and territories, all of these differences would
dards for the private sector. apply to the same project. These complexities present
significant challenges to researchers in both interpreta-
In addition, each state and territory has additional juris- tion and research conduct logistics. 92
dictional regulatory guidelines that apply to privacy and
use and disclosure of health information. The Northern In 2006, the Australian Health Ministers Advisory Council
Territory and Australian Capital Territory adhere only to (AHMAC) requested the NHMRC facilitate the develop-
the Commonwealth Privacy Act 1988. A summary of these ment and implementation of a national system where the
complex arrangements for the states, however, regarding single ethical review of a Human Research Ethics Com-
disclosure of personal health information, adapted from mittee (HREC) would be recognised by all institutions
91
Thomson, is as follows. participating in a collaborative research project. By having
a single ethical review outcome accepted by collaborating
For access to state hospital health information that is held institutions, protection of human participants would be
by state hospitals within Australia the Commonwealth maintained while delays due to the practice of seeking
Privacy Act does not apply and state regulation does multiple ethical reviews would be mitigated and time-
apply: whether specific legislation (New South Wales and lines for research start-up and results would be
Victoria) or regulatory instruments (Queensland) or shortened.
administrative directions (South Australia and Tasmania)
or administrative practices (Western Australia). Several states have developed formal systems for stream-
lining ethical review processes in public health organisa-
● Victoria: The Health Records Act 2001 (Vic.) and the tions. Other jurisdictions have informal arrangements
Information Privacy Act 2000 (Vic.) permit disclosure operating as agreements of acceptance between institu-
if it is reasonably necessary for research in the tions in the private and the public sectors and between
public interest; if it is impracticable to seek consent; public health organisations and universities.
if the agency believes that the recipient will not dis-
close the information; that the publication does not AHMAC’s direction that State and Territory systems
identify individuals and there is a favourable HREC should be ‘harmonised’ recognised that jurisdictional
review. statutory and administrative frameworks impacting
● Queensland: In a Queensland hospital, Information research in public health organisations differ.
Standard 42A imposes the same criteria as the The benefits of adopting a national approach to single
federal NPPs. It must be impracticable to seek consent ethical review are many, for example:
and an HREC must complete a favourable review,
using the guidelines under Information Standard ● The amount of time from ethical review application
42A. However, section 63F of the Health Services to research start-up is shortened, resulting in savings
Act 1991 (Qld) permits disclosure of information in human and monetary resources.

Ethical Issues in Critical Care 95

● Australia’s attractiveness as a place for international Data: Use and Disclosure
investment in commercial sponsored clinical trials is As noted earlier, ‘use’ of data refers to use internally
enhanced. within an organisation, whereas ‘disclosure’ refers to use
● Public confidence in the rigour of Australia’s system of data externally to the institution or place of collection.
of ethical review of human research is increased due It is usual for hospitals and health organisations to have
to the standardisation of ethical review processes. strict requirements regarding access to a person’s health/
● The roles and responsibilities of the researcher, the medical record for research purposes.
institution, the HREC and other key stakeholders in
the conduct of multi-centre research are transparent Use of codes in data collection sheets or computer records
and consistent. 93 should not contain patient/subject identifiers. Data
should not be used so as to cause material, emotional or
In New Zealand:
other disadvantage to any participant, nor should it be
● Single-region applications go to one of six regional used for any purpose(s) other than those specified in the
committees, and proposals involving more than one HREC-approved protocol. No more information than
region are assessed by a national multi-region ethics that specifically needed to accomplish the study must be
committee. recorded. 8,94 Attention to this is important, because a data
● ECs in NZ may request a second opinion from the collector will usually be privy to the entire health record.
Health Research Council Ethics Committee. It is therefore imperative that anyone extracting data
● Applicants may appeal decisions to the National understand that only approved data are removed used
Ethics Advisory Committee. and/or disclosed. It is usual for the examination of the
health records to occur on-site, with no record removed
See Online resources for further information.
19
from the hospital/organisation. The revised Joint
NHMRC and AVCC Statement and Guidelines on Research
RESEARCH INVOLVING Practice (1997) is now the Australian Code for the Respon-
UNCONSCIOUS PERSONS sible Conduct of Research (2007). It recommends that data
The question of whether it is justified to include an be securely stored for a minimum of 5 years from publi-
cation date, with a minimum of 15 years for data derived
unconscious patient in a research project without his or from clinical research. 95
her consent is the most difficult one facing critical care
researchers and ECs. 8,92 Paramount in these consider-
ations is the careful weighing of potential risks and ben- ETHICS IN PUBLICATION
efits by a competent individual. However, analysis of Journal editors are increasingly requiring that researchers
these risks and benefits by a surrogate on behalf of an demonstrate evidence of their ethics review process before
incompetent individual poses a range of ethical difficul- a manuscript/study is considered for publication (see
ties. Most national and international guidelines concur http://www.icmje.org). The Australian Code for the Respon-
that such research is justified as long as certain safeguards sible Conduct of Research (2007) provides guidance on the
are in place. minimum requirements for authorship of research.
Authorship is defined as substantial participation, where
8
Both the National Statement and the Operational Stan- all the following conditions are met: 95
12
dards outline categories of vulnerable persons and the
relevant ethical considerations that apply to these groups. ● conception and design, or data collection or analysis/
The governing bodies recommend careful consideration interpretation of data
of these highly vulnerable groups. Of note, the New ● drafting the article, or revising it critically for impor-
12
Zealand Operational Standards recognise that research tant intellectual content
on unconscious patients is appropriate, but emphasise ● final approval of the version to be published.
the need for communication with the family or other Authors must also ensure that all those who have con-
legal representatives wherever possible. These Standards tributed to the work are recognised and acknowledged.
do note that in emergency situations consultation with Acquisition of research funding or general supervision of
the family/legal representatives may not be possible, but a research group is not considered sufficient for author-
that the ‘health care practitioner must always act in the ship. Intellectual honesty should be paramount and
best interests of the consumer’. 12
used to inform publication ethics and to prevent
misconduct. 95
RESPONSIBLE RESEARCH PRACTICES
Ethical integrity must be maintained throughout all CLINICAL TRIALS
phases of clinical research, including research design, The Therapeutic Goods Administration (TGA) in Australia
conduct, monitoring, data management and dissemina- has adopted the Note for Guidance on Good Clinical Practice
tion. This ethical integrity is reflected in the demonstrated (CPMP/ICH/135/95) to replace the Guidelines for Good
rigour throughout any given study. An understanding Clinical Research Practice (GCRP), but at the same time
of the relevant ‘responsible research practices’ is needed notes there is some overlap with The National Statement
to be able to ensure fulfilment of ethical integrity which prevails. The TGA has published an annotated
requirements. Some key primary examples are discussed version for the Australian regulatory context. The Note for
here. Guidance on Good Clinical Practice (CPMP/ICH/135/95) is

96 S C O P E O F C R I T I C A L C A R E

an internationally accepted standard for the designing, incompetent regarding autonomous decision making.
conducting, recording and reporting of clinical trials. Hence, critical care nurses need to be familiar with guiding
ethical principles in the care of the critically ill, and with
The Australian government, through the NHMRC, has
funded and established the Australian Clinical Trial Regi- the ethical considerations relating to the conduct of clini-
stry (ACTR) at the NHMRC Trials Centre in Sydney, which cal human research. While a broad knowledge of these
complies with these requirements. Clinical trials can be principles is a requirement for all health professionals,
registered online. For trials commencing recruitment after because critical care nurses are often involved in these
1 July 2005, registration must occur prior to subject discussions and debates, they need to be particularly well
recruitment, as there are important implications for future informed, in order to actively participate in ethical deci-
research publication in journals. In parallel, as more sion making.
national trial registries emerge, the World Health Organi- Critical care nurses have a unique position, as they are at
zation is developing an approval process to assess trial the patient bedside around the clock and are often side-
register compliance. The WHO International Clinical Trial by-side with relatives for many hours at a time. Respon-
Registry Platform (ICTRP) is a global project to facilitate sibilities include acting as patient advocate, with often a
access to information about controlled trials and their counselling and listening role at the bedside with rela-
results. The Clinical Trials Search Portal provides access to tives of the critically ill. Medical officers in the critical care
a central database containing the trial registration data unit have additional legal responsibilities surrounding
sets provided by the registries listed on the right. It also consent and end-of-life decision making. A multidisci-
provides links to the full original records. To facilitate the plinary approach is therefore both useful and prudent to
unique identification of trials, the Search Portal bridges ensure all relevant ethical matters are considered appro-
(groups together) multiple records about the same trial. 96 priately and that treatments and care are conducted
according to guiding ethical principles. Issues of consent,
SUMMARY organ donation, guardianship, privacy, research and end-
of-life decision making are complex. The use of addi-
Effectively dealing with ethical issues in any healthcare tional supportive guiding processes and resources is
setting is complex and at times contentious. This is highly recommended to give the critical care nurse ade-
even more so in the critical care environment, where quate information on these ethical matters – those of
the patient cohort is predominantly vulnerable and paramount importance in the care of the critically ill.



Case study
Patients admitted to ICU frequently suffer from life-threatening Her temperature is 39.5 °C; WBC-15, 3000. Urine output is 30–40 cc/
situations. In a few instances, patients are non-responsive to ICU hr. She is sleepy but arousable.
therapies leading to the discontinuation of life sustaining interven-
tions (i.e drip of inotrope drugs, haemodialysis). A patient’s culture Her chest X-ray shows bilateral infiltrates and Mary is diagnosed
can influence many aspects of life, including family dynamics, with Pneumocystis carinii pneumonia. Mary was admitted to the
coping styles, and perceptions of death and dying, as well as the ICU for treatment. She is intubated, and treated with the appro-
expectations that people have from the health care system. Deci- priate drugs. Within 3 weeks, Mary was in septic shock, multi-
sions of patients, families and health care providers about health organ failure, unresponsive to high dose inotropic drugs, receiving
care at the end of life also depend on many factors. These include continual haemofiltration for acute kidney failure, spontaneous
relevant healthcare data, the doctor–patient relationship, institu- sub arachnoid haemorrhage and GCS of 3 without sedatives.
tional rules and regulations, and the general sociocultural, ethical, The ICU doctors and the haematology consultants consider that
legal and religious principles of the society. Several studies have any further treatments are futile and make the recommendation
shown that some of the differences in end-of-life decision making for therapy to be discontinued. The nursing staff has developed
are associated with local cultural factors. These differences fre- a close relationship with Mary’s husband, parents and the chil-
quently lead to conflicts in care decisions between health care staff dren, and do not feel ready to stop therapy. Mary’s parents and
and the patient’s family regarding continuation of life sustaining husband refuse to withdraw or withhold any therapies. They
interventions. believe that Mary should continue all treatments that she is
receiving now, and a natural course including palliative care
Mary is a 44-year-old wife and mother of 5 children; the youngest should be maintained. They are praying that a miracle will happen.
child is 5 years old. Mary and her family are very religious and The ethical challenges identified throughout this period were
devout Christian Scientists. She was diagnosed with acute lym- complex. There was mild dissent among nurses and medical staff
phatic leukaemia one month ago and has received two doses of at varying times, as personal belief systems reflected differing
chemotherapy. Last night Mary presented to the emergency views about Mary’s proposed treatment or cessation of treatment
department, primarily with the complaint of shortness of breath at and clinical course. There was a view in the last few days by a
rest. She is accompanied by her husband.
number of nurses that she had ‘suffered enough’ and her condition
Arterial blood gases results taken with many receiving 10L of O 2 was ‘futile’. The medical and nursing team felt that honouring the
via a face mask included: PaO 2 65 mmHg, PaCO 2 54; pH 7.50; patient’s and family’s religious belief was in conflict with the
BE+4.4; Lactate 4.9. healthcare situation. Nurses trained in cultural competence felt

Ethical Issues in Critical Care 97



Case study, Continued
insensitive in convincing the family to forgo life sustaining ICU nurse manager
therapies. ● diverse responsibilities to colleagues, patient, family and hos-
pital require an understanding of ethics and the law, profes-
The ethical impact of Mary’s stay is summarised in key perspectives
of those involved in her care. sional codes of practice, and sensitivity to both staff and
patient needs.
Nurses: The hospital’s clinical ethicist and clinical ethics committee was
● reported to be physically and mentally drained consulted and all options were discussed with the family, with
● ethical dilemmas complicated by differing personal beliefs sensitivity to their religious views. It was decided that all current
● patient allocation difficulties treatments would be continued, no new treatments would com-
● stressed, frustrated, burnout mence and ‘nature would take its course’.
● each describing how they were affected in different ways
● needed to be sensitive to family’s views A staff debriefing was conducted by independent external coun-
● debriefing should have been considered earlier and sellors and was positively received by all staff. Staff comments
regularly reflected their personal ethical and professional struggles that they
● were they advocating for the patient’s best interest or the openly shared in this confidential forum.
family’s? What lessons can be learnt from this case study? Culturally-
● what were the patient’s best interests?
challenging patients and families can significantly affect many
Doctors: resources, and most crucially the patient and staff. They also
● varied opinions, mild dissent, communication challenges at present many ethical and clinical challenges. These families may
times discussing the advantages and disadvantages of extend- have a feeling of isolation and lack of support from the medical
ing ’futile’ care and nursing team. The teams may feel overwhelming difficulties
● communication barrier between themselves, nursing team when dealing with a family that desire measures not advised
and the family. by them.
Family: Staff described variable rewards and/or stress levels, ranging from
● physical and emotional exhaustion negligible to great. Increased focus on clinical and personal
● insistence on full treatment support for staff, including an awareness of the diverse sensitivi-
● children traumatised ties, is essential when caring for culturally-challenging critical care
● receiving support for their decisions from a spiritual source patients. Staff require consistent support personally and profes-
rather than from the medical team sionally. Awareness of sensitivities regarding nursing allocation to
● felt anger and aggression from medical team. patient care including fair rotations is important, in addition to
provision of education for nurses regarding ethical principles,
Patient ethical conduct, and their obligations as critical care nurses. Patient
● does she feel that she has suffered enough? advocacy is also paramount, as is the establishment of early forma-
● is she waiting for a miracle? tive and open communication with patients and their loved ones.






Research vignette

Benbenishty J. DeKeyser Ganz F, Lippert A, Bulow FH, Wennberg E, Setting
Henderson B, Svantesson M, Baras M, Phelan D, Maia P, Sprung CL, The study took place in 37 intensive care units in 17 European
Nurse Involvement in end-of-life decision making: the ETHICUS countries. Patients and participants: Physician investigators
Study. Intensive Care Medicine 2006 32: 129–32. reported data related to patients from 37 centres in 17 European
countries. Interventions: None.
Abstract
Objective Measurements and results
The purpose was to investigate physicians’ perceptions of the role Physicians perceived nurses as involved in 2412 (78.3%) of the 3086
of European intensive care nurses in end-of-life decision making. end-of-life decisions (EOLD) made. Nurses were thought to initiate
Design: This study was part of a larger study sponsored by the the discussion in 66 cases (2.1%), while ICU physicians were cited
Ethics Section of the European Society of Intensive Care Medicine, in 2,438 cases (79.3%), the primary physician in 328 cases (10.7%),
the ETHICUS Study. Physicians described whether they thought the consulting physician in 105 cases (3.4%), the family in 119 cases
nurses were involved in such decisions, whether nurses initiated (3.9%) and the patient in 19 cases (0.6%). In only 20 responses
such a discussion and whether there was agreement between phy- (0.6%) did physicians report disagreement between physicians and
sicians and nurses. The items were analysed and comparisons were nurses related to EOLD. A significant association was found
made between different regions within Europe. between the region and responses to the items related to nursing.

98 S C O P E O F C R I T I C A L C A R E



Research vignette, Continued
Physicians in more northern regions reported more nurse conflicts. Data on perceived conflicts in the week prior to the
involvement. survey day were obtained from 7498 ICU staff members (323 ICUs
in 24 countries). Conflicts were perceived by 5268 (71.6%) respon-
Conclusions
Physicians perceive nurses as involved to a large extent in EOLDs, dents. Nurse-physician conflicts were the most common (32.6%),
but not as initiating the discussion. Once a decision is made, there although doctors were less likely to report conflicts than were
is a sense of agreement. The level of perceived participation is dif- other staff members. This emphasises the lack of reliability of using
ferent for different regions. physician reports as the data collection method in the ETHICUS
study.
Critique The ETHICUS study found significant geographical and regional
This study explored ICU physicians’ perceptions of nurse involve- differences that influenced physicians’ perceptions of nurses’ EOL
ment. The underlying assumptions in this study are potentially participation. Nurses in northern Europe were perceived to be
flawed for a number of reasons. First, nurses and physicians are more involved in such decisions. These differences might reflect
known to communicate differently and to hold different percep- variants in the working cultures and professional roles within dif-
tions regarding the quality of collaboration and communication. ferent regions. Nurses in the northern region may have a more
97
It is therefore possible that physicians’ perceptions bear no rela- collegial role with physicians with respect to EOLDs. These
tionship to levels of actual nurse involvement. It would have been responses might also be due to the considerable variation across
beneficial to explore the similarities and differences between phy- Europe that exists in the legislation and practice of withdrawing
sicians’ and nurses’ perceptions in this important, and often diffi- and withholding treatment. For example, Rubulotta relates
99
100
cult, area of clinical decision making.
that the Italian National Society of Anaesthesia, Analgesia, Resus-
Second, the data were collected and submitted by senior ICU phy- citation and Intensive Care has stated, ‘still it seems that the physi-
sician decision makers at each institution. It is not clear what clini- cian (single person) should ultimately decide to limit care by either
cal involvement or work patterns these physicians had and not initiating or suspending intensive care in a specific patient’.
therefore whether they were familiar with the practices under- Culturally, Italian families expect doctors to make final EOL deci-
taken throughout the 24 hours of each day, or primarily involved sions. As a consequence, nursing staff may not be asked for their
100
in the discussions and decisions that occur during ‘office hours’. opinion or families may be unwilling to discuss EOL issues with
nurses.
There is little information provided in this report detailing the
method used to collect the study data, although further details can A further concern raised by the results is that 17% of respondents
be gained by accessing an additional publication. It is not clear indicated the question regarding agreement between nurses and
98
how participation in the study was sought, nor whether the centres physicians was not applicable. The reason behind this lack of appli-
that participated were representative of European ICUs in general. cability is not clear. It is possible the physicians thought the ques-
Given that only 37 centres in 17 countries, or an average of only tion was inappropriate because of no disagreement in the area, or
two centres in each country participated, the results may not be alternatively that they considered nurses should not be involved
representative of practice and decision making across each in such decisions and therefore any question about their participa-
country. tion was inappropriate.
Bearing in mind the above limitations, the physicians in this study While this study report raises more questions than it answers, it
indicated a high level of agreement between nurses and physicians does emphasise the importance of EOLD and the need for improved
in EOLD. This is in contrast to the evidence that conflicts are processes throughout the international practice arena. Families of
99
common and harmful in the ICU. Instances where physicians critically ill patients generally benefit from receiving consistent
relate nurses’ practice often lead to discrepancies and conflicts. information from all members of the health care team. As a result
Azoulay et al. attempted to measure the extent of conflicts occur- implementation of strategies to optimise involvement of all
ring in global ICUs, in an international study. The CONFLICUS members of the health care team and ensure agreement between
98
study was a one-day cross-sectional survey of ICU clinicians nurses and physicians and the delivery of a consistent message are
recording the prevalence, characteristics, and factors of ICU likely to be beneficial.



Learning activities

Learning activities 1–4 relate to the Case study. 5. Because critical care patients are often incompetent and
1. What might be some of the positive aspects of caring for unable to provide informed consent for procedures, consent is
patients like Mary? often implied. What are the boundaries of implied consent, and
2. What might be some of the challenging aspects of caring for a what must critical care nurses be conscious of in relying on
patient like Mary? implied consent for treatment?
3. What considerations or issues should be taken into account by 6. The ANMC Code of Ethics for Nurses contains six broad value
the healthcare team when making decisions in the care of a statements (see Box 5.1). Reflect on the degree to which your
similar patient? practice demonstrates these values. Consider how these values
4. What strategies may be useful for staff to adopt when caring relate to critical care practice. Discuss these values with your
for culturally challenging patients in critical care? critical care colleagues.

Ethical Issues in Critical Care 99



Learning activities, Continued
7. The Nursing Council of New Zealand Code of Conduct for 8. Aveyard suggested that the concept of informed consent prior
Nurses contains four principles (see Box 5.2). Principle 2 specifi- to nursing care procedures is undeveloped, and that this may
cally contains criteria that relate to acting ethically and main- lead to unwanted and inappropriate delivery of care. Reflect
17
taining standards of practice. Reflect on the degree to which on your practice in the critical care setting in relation to how
your practice demonstrates these values. Consider how these you obtain informed consent for nursing activities.
values relate to critical care practice. Discuss the values with
your critical care colleagues.


RELEVANT LEGISLATION National Health and Medical Research Council (NHMRC), Values and
Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander
New Zealand Acts Health Research, http://www.health.gov.au/nhmrc/publications/synopses/
e52syn.htm
● Privacy Act 1993 National Health and Medical Research Council (NHMRC) & Australian
● Public Health and Disability Act 2000 Vice-Chancellor’s Committee (AVCC), Joint NHMRC/AVCC Statement and
Guidelines on Research Practice, 1997, http://www.nhmrc.gov.au/funding/
Australian Acts policy/researchprac.htm
New Zealand Privacy Commissioner website,www.privacy.org.nz
● Health Records (Privacy and Access) Act 1997 (ACT) New Zealand multi-region ethics committees, http://www.newhealth.govt.nz/
● Information Act 2002 (NT) ethicscommittees/committees/multi-region.htm
● Health Records and Information Privacy Act 2002 (NSW) NHS Organ Donation Register Wall of Life, www.walloflife.org.uk
● Health Records Act 2001 (Vic.) Standards Australia Personal Privacy Protection in Health Care Information Systems
(AS4400-1995),http://www.standards.com.au
● Privacy Act 1988, s. 6 (Cwlth) Therapeutic Goods Administration, Human Research Ethics Committees and the
● Health Records and Information Privacy Act 2002, s. Therapeutic Goods Legislation, Department of Health & Aged Care, Can-
4(NSW) berra,2001, http://www.tga.gov.au/pdf/docs/unapproved/hrec.pdf
● Information Act 2002, s. 5(NT) US Department of Health and Human Services and Other Federal Agencies
Common Rule. 45 Code of Federal Regulations 46, (1991), http://ohsr.od.nih.gov/
● Health Records Act 2001, s. 3(Vic.) guidelines/45cfr46.html
● Information Privacy Act 2000 (Vic.) World Health Organization, Operational Gudelines for Ethics Committees that
● Health Services Act 1991 (Qld) Review Biomedical Research (2000), http://apps.who.int/tdr/svc/publications/
● Privacy and Personal Information Protection Act 1998 training-guideline-publications/operational-guidelines-ethics-biomedical-
research
(NSW) World Medical Association, Declaration of Helsinki updated 2008, http://www.
hrc.govt.nz/assets/pdfs/publications/17c.pdf
ONLINE RESOURCES
The Australian Organ and Tissue Authority (AOTA), http://www.donatelife.gov.au FURTHER READING
Council for International Organisations of Medical Sciences (CIOMS), Interna-
tional Guidelines for Biomedical Research Involving Human Subjects. (1993, revised Benatar S. Reflections and recommendations on research ethics in developing
in August 2002); International Guidelines for Epidemiological Research (1991), countries. Soc Sci Med 2002; 54(7): 1131–41.
http://www.cioms.ch/ Bhutta ZA. Ethics in international health research: a perspective from the develop-
Health Research Council of New Zealand (HRCNZ), Guidelines for Researchers ing world. Bull World Health Organ 2002; 80(2): 114–20.
on Health Research Involving Maori, http://www.hrc.govt.nz/root/Ethics/ DeAngelis CD, Drazen J, Frizelle FA, Haug C, Hoey J et al. Clinical trial registra-
Guidelines_and_Publications.html tion: a statement from the International Committee of Medical Journal
Health Research Council of New Zealand (HRCNZ), http://www.hrc.govt.nz/root/ Editors. JAMA 2004; 292: 1363–4.
Ethics/Guidelines_and_Publications.html Emmanuel EJ, Wendler D, Killen J, Grady C. What makes clinical research in
Medical Research Council of Canada (MRC), National Science and Engineering developing countries ethical? The benchmarks of ethical research. J Infect Dis
Research Council of Canada (NSERC) & the Social Science and Humanities 2004; 189: 930–37.
Research Council of Canada (SSHRC), Tri-Council Policy Statement: Ethical Gillon, R. End-of-life decisions. J Med Ethics 1999; 25:435–6.
Conduct for Research involving Humans, Ottawa, MRC, NSERC & SSHRC, 1998, Lavery JV, Grady C, Wahl ER, Emanuel EJ. Ethical issues in international biomedical
http://www.ncehr-cnerh.org/english/code _ 2 research: a casebook. Oxford: Oxford University Press; 2007.
National Ethics Advisory Committee, http://www.newhealth.govt.nz/neac Sonnenblick M. Advanced medical directives. Harefuah 2002; 141(2): 181–8.
National Health and Medical Research Council (NHMRC), Organs Retained Organ Donation Taskforce Implementation Programme; Working together to save
at Autopsy: Ethical and Practical Issues, http://www.health.gov.au/nhmrc/ lives: The Organ Donation Taskforce Implementation Programme Annual Report
publications/synopses/e41syn.htm 2008/2009, Department of Health, London. Available from: http://www.bts.
National Health and Medical Research Council (NHMRC), National Statement on org.uk/transplantation/organ-donation-taskforce/
Ethical Conduct in Human Research 2007, http://www.health.gov.au/nhmrc/
publications/synopses/e35syn.htm
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Principles and Practice of


Critical Care

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Essential Nursing Care of


the Critically Ill Patient 6





Bernadette Grealy
Wendy Chaboyer



important component of quality care; if patients are
Learning objectives assessed thoroughly and on a continuing basis then prob-
lems may be detected and treated early, preventing the
After reading this chapter, you should be able to: development of unnecessary complications. These prin-
● identify risks posed to critically ill patients relating to ciples underpin this chapter. Additionally, it is important
inadequate physical care and hygiene always to treat the patient as a person. Although this
● describe best practice in the provision of physical care and chapter focuses on the physical dimension of nursing care,
hygiene patients’ psychosocial care should not be ignored (see
● understand the key elements of safe transfer of critically ill Chapters 7 and 8). Further, while this chapter describes
patients within the hospital setting essential nursing care, care bundles, which encompass a
● understand the principles of infection-control risk number of these activities, are described in Chapter 3.
identification and management for critically ill patients

Practice tip

Make sure patients know your name when you are caring for
Key words them; introducing yourself is professionally appropriate and
reassuring to patients.
bowel management
eye care
infection control PERSONAL HYGIENE
intrahospital transport
oral care It is important to provide the critically ill patient with
patient positioning and mobility effective personal hygiene as poor hygiene may increase
the risk of bacterial colonisation and subsequent infec-
personal hygiene tion, or lead to surgical infection. Daily bed-baths are
1
2
urinary catheter care
usually provided for most critically ill patients, although
their effectiveness at reducing bacterial colonisation is
1
questionable. Personal hygiene is also closely related to
an individual’s esteem and sense of wellbeing. It may also
INTRODUCTION influence family members’ perception of the quality of
This chapter is about essential nursing care. Because it is care the patient is receiving and the confidence they have
often referred to as basic nursing, nurses may not always in the staff’s ability to care for their loved one.
perceive it as deserving of priority. Yet, how well patients Consideration of the patient’s specific condition may
are cared for has a direct effect on their sense of wellbeing influence the timing and way personal hygiene is per-
and their recovery. This chapter focuses on the physical formed. For example, the patient may have to be moved
care, infection control, preventative therapies and trans- slowly when changing bed linen because of their cardio-
port of critically ill patients. The first two areas are closely vascular instability, or they may require a blanket while
linked: poor-quality physical care increases the risk of bathing if they are hypothermic. Finally, providing essen-
infection. The final areas are essential features of critical tial care should be timed to promote optimal rest.
care nursing.
Comfort is a paramount concern in intensive care. The ASSESSMENT OF PERSONAL HYGIENE
two key areas of care – reducing risk and providing quality Assessment of critical care patients’ personal hygiene
care – are closely related and served by a series of princi- should be undertaken on two levels: first, determining
ples (see Table 6.1). Good risk management is an what patients are able to do for themselves and what they 105

106 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



TABLE 6.1 Principles of practice TABLE 6.2 Skin and tissue assessment

Reducing risks to patients Provision of quality care Factor Observations
● Recognition of the specific ● Development of knowledge Colour of the skin ● Jaundice, erythema, pallor, cyanosis
needs of critically ill patients, and skills for practice
particularly those who are ● Evidence based practice Condition of the skin ● Skin turgor (elasticity): evidence of
unconscious, sedated or ● Optimal use of protocol- oedema (taut skin), dehydration
immobile driven therapy (dryness, tenting of the skin),
● Recognition of specific ● Competent, efficient and age-related or steroid-related
complications that may safe practice damage (thin, papery, easily torn
require special observation ● Selection and application of skin), skin tears
or treatment appropriate nursing ● Presence of: rash, cellulitis, irritation,
● Vigilant monitoring and early interventions bruising, swelling
recognition of signs of ● Monitoring the Tissue perfusion ● Hypoperfusion: capillary refill time,
deterioration consequences of nursing cool extremities, pulse strength and
● Selection, implementation interventions volume, blanching of the skin
and evaluation of specific ● Review and evaluation of ● Hyperaemia: very warm, red areas of
preventive measures nursing practices skin
● Management of potentially ● Continuity of care ● Thrombus formation: warm, red,
detrimental environmental ● Effective critical care team swollen areas (especially calves)
factors that may affect the functioning
patient Moisture ● Excessive sweating
● Skin damage caused by moisture,
especially: skinfolds, under the
breasts, in the groin, between the
buttocks
want and second, the nurse’s professional assessment of Wounds, drains, ● Evidence of inflammation, infection,
what is required. As with all aspects of care, the patient cannulae, catheters pressure damage, skin excoriation
has the right to refuse personal hygiene measures. Many caused by leaking exudates, correct
positioning of drains, need to redress
critical care patients are unable to participate in decision wounds
making, and in these cases it falls to the nurse at the
bedside to determine what level of care is necessary.
Washing patients provides opportunities for the nurse to
assess the patient’s skin and tissue. Often this enables the completing personal hygiene and interruptions that affect
nurse to: pick up vital clues about the patient’s health the dignity of the patient. Privacy for the patient during
status; identify tissue damage that requires treatment; and personal hygiene should be of paramount concern.
identify dressings or wounds that require attention. There The length of time taken to wash a patient and the envi-
are a number of areas to consider when assessing the skin ronmental temperature are factors that affect cooling.
(see Table 6.2). Excessive moisture on the patient’s skin Water on exposed skin causes rapid heat loss through
from sweat can be problematic, particularly in skinfolds. conduction, convection and radiation, and for many
Perspiration is a normal insensible loss, and is invisible. years tepid sponging was used in critical care as a method
Body sweat is usually related to temperature and is of cooling pyrexic patients. Vasoconstriction increases
3
observed on all skin surfaces, especially the forehead, the patient’s perception of cold and the possibility of
axillae and groins. Emotional sweating is stress-related shivering, which can affect the patient’s cardiovascular
4
and is observed on the palms of the hands, soles of the stability. When shivering occurs, vulnerable patients, with
feet, forehead and axillae. low energy reserves, can rapidly use energy to keep warm.
The higher oxygen consumption associated with shiver-
BASIC HYGIENE ing may be particularly significant in elderly patients. 4
A daily bed-bath with intermittent washes of the face and A range of cleansing solutions is available for washing.
hands is standard care, however patients who are sweat- Although soap is effective in facilitating the removal of
ing, incontinent, bleeding or with leaking wounds should bacteria, it can cause dryness of the skin. Aqueous cream,
be washed and their linen changed as often as necessary. which can be used as a soap substitute, or emulsifying
Wet, creased sheets may cause pressure on dependent ointments are preferable, as they have moisturising pro-
areas, increasing the risk of pressure ulcer development. perties, although the latter is greasier. Topical emollients
5
For many critically ill patients, being moved is painful (moisturisers) either trap water or draw water into the
and it may be appropriate to give prophylactic pain relief dermis, and help to protect damaged skin by creating a
before commencing a bed-bath.
5
waterproof barrier. Baby care products are often used,
The timing of a bed-bath and personal hygiene is impor- although these may be the least effective due to their low
5
tant. When several nurses are required to move the oil content. Specific topical treatments may be required
patient, it makes sense to consult with colleagues to coor- for patients with skin diseases such as dermatitis. Dispos-
dinate their availability. Planning ahead with respect to able cloths should be used for washing, as linen flannels
events such as medical rounds, chest X-ray requirements have been shown to harbour bacteria. Complete dispos-
and family visits helps avoid unnecessary delays in able wash kits are available with potential advantages of

Essential Nursing Care of the Critically Ill Patient 107

being effective for patient’s skin cleaning without requir-
ing rinsing and therefore drying the skin, and being dis- TABLE 6.3 Treatment of skin tears
posable may reduce potential for infection and certainly
reduces linen costs. 1 Factor Interventions
Personal hygiene involves washing the patient’s hair as Cleansing ● Gently clean skin with saline or non-toxic
necessary, shaving the patient, management of cerumen wound cleaner
in ears and care of finger and toe nails. While normal ● Allow to dry or pat dry carefully
shampoo can be used, hair caps and washing products Skin flap ● Approximate the skin tear flap/tissue, if
are available that are easier to use for bed ridden patients. present, as closely as possible
Male facial hair should be managed as per the patient’s Dressing ● Provide appropriate topical wound care,
normal routine, such as maintaining a beard or shaving. such as a moist wound dressing.
Ears should be gently inspected for debris or injury. If ● Remove any product with an adhesive
assessed as appropriate, wax softening drops may be backing with utmost care to avoid further
trauma
needed for 3–5 days if cerumen is present and causing ● Secure non-adherent dressing with a gauze
6
the patient difficulties with their hearing. Maintaining or tubular non-adhesive wrap
clean nails is another aspect of personal hygiene. Care ● Change dressings according to the
should be taken if nails require trimming, especially if manufacturer’s recommendations
the patient has brittle nails or is diabetic. Documentation ● Record details of skin tear, describe or
photograph wound, record details of
dressings and implementation of measures
to reduce risk of further occurrences
Practice tip

While personal grooming is not vital from a health perspective,
it is a factor in how we see ourselves and how others identify Practice tip
with us. With the many changes that come with illness and Monitor any bruising regularly, as such areas may be at risk of
therapies applied in critical care, it is important to keep the developing skin tears.
patient’s ‘look’ as normal as possible – simple things such as
styling hair or trimming beards – if not for the patients them-
selves, who might be unaware, then for their families.
EYE CARE

The eyes are one of the most sensitive parts of the human
body. If their eyes are not properly cared for, critical care
Skin Tears patients may spend many hours in unnecessary discom-
Dependent patients who require total care are at greatest fort. Simple bedside procedures like turning on lights at
risk of skin tears. Injuries result from routine activities night or assessing pupil reactions can be uncomfortable.
such as dressing, bathing, positioning and transferring. There are a number of physiological processes that protect
7
The elderly, those with fragile skin (particularly those the eye. For example, the eye is protected from dryness by
with a history of previous skin tears), those who require frequent lubrication facilitated by blinking. Antimicro-
the use of devices to assist lifting, those who are cogni- bial substances in tears help prevent infection, and the
tively or sensorily impaired, and those who have skin tear ducts provide drainage. When the eye is unable to
8
problems such as oedema, purpura or ecchymosis are at close properly, tear film evaporates more quickly. If any
greatest risk. Most skin tears occur on the arms and the of these defence mechanisms are compromised the eyes
8
back of the hands. The Payne-Martin classification system are at greater risk.
uses three categories to describe skin tears: skin tears There is considerable risk to patients’ eyes while they are
without tissue loss; skin tears with partial tissue loss; and in the ICU. The blink response may be slowed or absent
9
skin tears with complete tissue loss.
in some patients, such as individuals receiving sedatives
Skin tears can be prevented by careful handling of patients and muscle relaxants, or those with Guillain–Barré syn-
10
to reduce skin friction and shear during repositioning drome. A number of complications can result, such as
and transfers. Padded bed rails, pillows and blankets can keratopathy, corneal ulceration and viral or bacterial con-
9
be used to protect and support arms and legs. Paper-type junctivitis. Corneal abrasions may occur within 48 hours
or non-adherent dressings should be used on frail skin, of ICU admission 11,12 and in up to 40–60% of critically
and should be removed gently and slowly. Wraps or nets ill patients. 8,12 When the eyes are exposed they are at
can be used instead of surgical tape to secure dressings greater risk of injury and infection, and conjunctival
13
and drains in place. Application of a moisturising lotion oedema can lead to subconjunctival haemorrhage. For
to dry skin helps to keep it adequately hydrated. Treat- the intensive care patient, who often has multiple intra-
7
ment of skin tears is outlined in Table 6.3. The focus of venous lines, nasogastric tubes, ventilation tubes and
nursing care should be on careful cleansing and protec- their various connections, there is potential to uninten-
tion of the skin tear to prevent further damage and docu- tionally damage one of the eyes with one of these devices
mentation of interventions and healing progress. during position changes.

108 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

EYE ASSESSMENT benefit from regular 4-hourly administration of artificial
9
Eye assessment should be undertaken at least every 12 tears to lubricate the eyes, although this may be unneces-
hours, even for the conscious patients who are able to sary while they are sleeping.
blink spontaneously and usually require minimal eye Dawson offers an eye care protocol for critically ill
care. The risk of corneal abrasion or iatrogenic trauma is patients, which clarifies the type of eye care required
greatest when patients are unable to close their eyes spon- according to the patient’s ability to maintain eye closure.
14
taneously, so these patients are at greatest risk of injury. The protocol requires an assessment to be made once per
14
The second at-risk group is those patients receiving posi- shift. Initially, eye closure is assessed to determine whether
tive pressure ventilation, who may develop conjunctival it is complete or whether the conjunctiva and/or the
oedema (chemosis), sometimes referred to as ‘ventilator cornea are exposed. Suggested treatment is 1–4-hourly
eye’. Third, patients who are exposed to high flows of air/ eyedrops, with further assessment to exclude keratitis or
9
oxygen, such as that with continuous positive airway conjunctivitis. Unconscious or paralysed patients are
pressure (CPAP) systems, may be vulnerable to its drying likely to require more eye care than conscious patients.
effects. Finally, all patients are at risk of eye inflammation Basic eye care consists of cleaning the sclera and sur-
and infection. Serious infections with bacteria such as rounding tissue and moistening the eyes by administer-
pseudomonas can progress rapidly, resulting in blindness ing artificial tears.
if not treated promptly.
For at-risk patients, the general consensus is that eye care
Initial assessment should focus on whether the patient should be performed using a sterile technique, cleansing
belongs to an at-risk group. Most critically ill patients are the eye from the inside to the outside usually with saline
at some risk, but particularly those who are unable to and gauze; however, eye care regimens have not been
9
close their eyes adequately. If the cornea is exposed, the rigorously researched. Cotton wool is not recommended
14
patient is considered to be in a high-risk group. Based because of the presence of particulates that may cause
on the groups identified above, initial assessment should corneal abrasions. Eyedrops should be administered
help determine how often eye assessment and eye care is gently, inserting the drop in the uppermost part of the
required. opened eye and as close to the eye as possible without
The general principles of eye assessment are shown in touching it. Sometimes eyedrops can sting, so it is advis-
Table 6.4, which should include a full examination of the able to warn the patient of this possibility. Regular sche-
eye’s external structure, colour and response. A number duled eye care with an ocular lubricant plus eye closure
9
of assessment tools have been developed for this purpose. with tape or wrap is used to reduce the potential for
Thorough eye assessment should assess appearance corneal abrasions or subsequent corneal ulceration or
(which may provide indications of disease or trauma) infection in patients who are either paralysed or heavily
15-17
and physical and neurological functions. If there is sedated.
concern about any aspect of a patient’s eyes, a referral for
assessment should be made to an ophthalmologist.
Practice tip
ESSENTIAL EYE CARE Another source of irritant to the eyes can be the constant air
The goals of eye care are to provide comfort and protect flow from air-conditioning vents or fans, so check that your
the eyes from injury and infection. Eye care and the patient at risk is not positioned directly in line with these vents
administration of artificial tears should be provided as or poorly-positioned fans.
required, if the patient complains of sore or dry eyes, or
if there is visible evidence of encrustation. If a patient is
receiving high-flow oxygen therapy via a mask, they may Conjunctival Oedema (Chemosis)
Conjunctival oedema (chemosis) is a common problem
associated with positive pressure ventilation, high posi-
tive end-expiratory pressure (PEEP) above 5 cmH 2 O and
18
TABLE 6.4 Assessment of the eyes prone positioning. While the oedema itself usually
9
resolves without treatment when ventilation is discontin-
External structure Colour Reaction ued, it may be advisable to seek an ophthalmic opinion
● Is it bulging or ● Is the sclera its ● Is the blink if there is concern. The literature is inconclusive concern-
misshapen? normal reflex ing the best method of treatment for conjunctival oedema,
● Is the pupil circular? off-white present? but evidence supports the use of artificial tear ointment
● What size are the colour or is ● Do both and maintaining eye closure as effective measures to
pupils? there evidence pupils react 9
● Are both pupils the of jaundice or to light with reduce corneal abrasions.
same size? haemorrhage? equal speed? Severe oedema often results in the patient’s inability to
● Is the pupil clear? ● Does it look red ● Is there a
● Is there any visible and inflamed? composite maintain eye closure. Under such circumstances, the
trauma? reaction to majority opinion is that eye closure may be maintained by
● Is it weeping? light in the applying a wide piece of adhesive tape horizontally to the
● Does it look dry or opposite eye? upper part of the eyelid. This usually anchors the lid in
9
moist?
the closed position, while allowing the eyelid to be opened

Essential Nursing Care of the Critically Ill Patient 109

for pupil assessment and access for eye care. It is not neces-
sary to change the tape at each pupil assessment using this BOX 6.1 Characteristics of a healthy mouth
method. However, the use of tape may be inappropriate
for patients whose skin is very friable. Furthermore, if the ● Pink, moist oral mucosa and gums. Absence of coating,
eyelid becomes sore and inflamed, taping should be dis- redness, ulceration or bleeding
continued and an alternative method employed to close ● Pink, moist tongue. No coating, cracking, blisters or areas of
19
the eyes, e.g. gel eye pads. When it is not possible to close redness
the eyes, artificial tear ointment has been shown to reduce ● Clean teeth/dentures; free of debris, plaque and dental
the incidence of corneal abrasion. 15 caries
● Well-fitting dentures
If it is difficult to maintain eye closure by taping the upper ● Adequate salivation
part of the eyelid, the entire eye can also be covered with ● Smooth and moist lips. No cracking, bleeding or
polyethylene film, which has been shown to reduce the ulceration
incidence of corneal abrasion. This should be changed ● No difficulties eating or swallowing (uncommon in ICU)
18
4-hourly with eye care and assessment. Commercially
available eye-closing tape products are also available
along with gel eye dressings which may be used instead
of polyethylene film. 20,21 Current evidence indicates that
polyethylene film is the superior and most cost-effective caused by grinding of teeth or biting of the tongue, and
product for maintaining the ocular surface. 9,21 reduce bacterial activity that leads to local and systemic
infection. 22
ORAL HYGIENE Oral care for an un-intubated conscious patient with a

Poor oral hygiene is unpleasant, causing halitosis and healthy mouth generally involves daily observation of the
discomfort. Although mouth care is one of the most basic mucosa and twice-daily toothbrushing with a non-irritant
22
22
nursing activities, in some cases lack of oral hygiene can fluoride toothpaste. In general, for unconscious patients
lead to serious complications or increase their risk, such oral care should be attended to 2-hourly, although the
as ventilator-associated pneumonia in the ventilated evidence is inconclusive and frequency ranges from 2- to
28
patient. Attendance to oral hygiene including the removal 12-hourly. If the mouth is unhealthy, it may be neces-
of dental plaque which harbours pathogens is an imptant sary to provide oral hygiene as often as every hour.
component of nursing care. 23-26 Using a well-developed The basic method for oral care is to use a soft toothbrush
oral protocol can improve the oral health of ICU and toothpaste (even for intubated patients), as this will
27
patients. However, the practice of mouth care is not assist with gum care as well as cleaning teeth. Tooth-
25
28
always evidence-based, although evidence supports paste loosens debris and fluoride helps to prevent dental
34
having a standardise oral care protocol to improve oral caries. However, if it is not rinsed away properly, tooth-
35
25
hygiene. Factors associated with poor quality of oral paste dries the oral mucosa. The practice of using mouth
care include lack of education, insufficient time, non- swabs only for oral hygiene is ineffective, and tooth-
36
prioritising of oral care, and the perception that it is brushes perform substantially better than foam swabs in
unpleasant. 29 removing plaque. 25,36,37 Mouth rinses have not conclu-
26
Saliva produces protective enzymes, but absence of mas- sively shown benefit, however they may be comfortable
tication, for example, due to the presence of an endotra- for the patient to use. Toothbrushing every 8 hours was
cheal tube or deep sedation, leads to a reduction in saliva recommended in a recent study as being an adjunct to
production. An endotracheal tube (ETT) can cause pres- other ventilator associated pneumonia prevention prac-
38
sure areas in the mouth (which may be exacerbated if the tices while use of chlorhexidine toothbrushing was
39
patient is oedematous) and may thus need to be relo- found to be of benefit in another study.
cated regularly to a different position in the patient’s Although it is an effective saliva stimulant, practices such
mouth. as the use of lemon and glycerine are outdated, as glyc-
erine causes reflex exhaustion of the saliva process, result-
ORAL ASSESSMENT ing in a dryer mouth. 22,25 Lemon juice is to be avoided,
37
Mouth care should be reviewed regularly based on a thor- as it can decalcify enamel. Commercial mouthwashes
ough assessment of the oral cavity. Several oral assess- moisten and soften the mucosa and help to loosen debris,
22
26
ment tools have been designed specifically for intubated which can be washed away. They must be used with
patients. 30-32 Essentially, a healthy mouth is characterised caution in patients with oral problems, due to their
by several factors, as identified in Box 6.1, and all potential to cause irritation and hypersensitivity. 22
33
of these areas should be assessed as a basis for good In addition to toothbrushing, regular sips of fluid or
oral care. mouthwashing with water is recommended. If the patient
is able to suck and swallow, small pieces of ice are very
ESSENTIAL ORAL CARE refreshing. Patients with clean mouths, who are febrile
Oral care aims to ensure a healthy oral mucosa, prevent and/or receiving antibiotics, should also have their
halitosis, maintain a clean and moist oral cavity, prevent mouths moistened often with water to prevent drying,
pressure sores from devices such as ETTs, prevent trauma coating and subsequent discomfort. Immunosuppressed

110 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

patients or those on high-dose antibiotics may also PATIENT POSITIONING AND
require antifungal treatment to treat oral thrush. MOBILISATION
There are many oral hygiene products and solutions avail-
22
able to suit the needs of all patients. Commercial Positioning patients correctly is important for their
mouthwashes should be used as a comfort measure to comfort and the reduction of complications associated
42
26
supplement toothbrushing. A range of other products with pressure areas and joint immobility. Lying in bed
43
are available to treat oral problems, for example benzy- for long periods can be a painful experience. Several
44-48
damine hydrochloride (anti-inflammatory), aqueous researchers describe neuromyopathy from critical
lignocaine (anaesthetic) and nystatin (antifungal). For illness and disuse atrophy from prolonged immobility
patients intubated for more than 24 hours, rates of noso- contributing to intensive care acquired weakness. This
comial pneumonia may be reduced by using twice-daily weakness may contribute to prolonged ventilation, inten-
chlorhexidine gluconate mouthwashes, 25,37,39,40 which sive care length of stay as well as delayed return to phy-
44-53
25
also prevent plaque accumulation. This has the disad- sical normality. Cardiovascular stability, respiratory
32
vantage of an unpleasant taste and can discolour teeth. function and cerebral or spinal function are all factors
For patients with crusty build-up on their teeth, a single that influence the positioning of patients in critical care
25
application of warm dilute solution of sodium bicarbon- areas. Modern beds and pressure-relieving devices have
ate powder with a toothbrush is effective in removing helped considerably to enhance the care of critically ill
debris and causes mucus to become less sticky, although patients.
its use has not be definitively tested. However, it can cause The primary goals of essential nursing care for patient
superficial burns and its use should be followed immedi- positioning are:
ately by a thorough water rinse of the mouth to return
the oral pH to normal. Hydrogen peroxide has an anti- ● to position the patient comfortably
22
plaque effect, but if incorrectly diluted it can cause pain ● to enhance therapeutic benefits
41
and burns to the oral mucosa and a predisposition to ● to prevent pressure ulcers
22
candida colonisation. It is not pleasant tasting and ● to ensure the limbs are supported appropriately and
sometimes rejected by patients although it is the sub- to maintain flexible joints
stance that impregnates some of the foam sticks available ● to facilitate patient activity to minimise muscle
for oral care. As a preventive measure, to reduce the atrophy
37
incidence of fungal colonisation, natural yoghurt may be ● to implement early mobilisation as the patient’s con-
used. Normal oral hygiene is followed by coating the dition allows.
mouth and tongue with yoghurt. There is growing evidence that early mobilisation is an
important aim for critically ill patients 51-55 and an essen-
Plastic water ampoules (10 mL) can be used to drip water
into the mouth for convenient administration to patients tial goal of nursing care is to support the patient in main-
unable to easily open their mouths or swallow. A Yankauer taining or attaining a normal level of physical function
suction catheter facilitates rinsing of toothpaste from the for mobility. As with many other aspects of care for the
mouth, and a bite-guard device may be used temporarily critically ill, this is best achieved through multidisci-
to prevent patients from inadvertently biting on the plinary team members working together. Here, physio-
toothbrush or their tongue. They should not be used long therapists and occupational therapists have a lead role in
term due to the risk of pressure sores. Lanolin may be assessing patients and planning programs of care and
applied to help maintain integrity of the lips. activity to facilitate attaining the goals of normal physical
function, while nurses contribute by ensuring the pro-
grams of care are delivered when other personnel are not
available.
Practice tip

If the patient objects to the taste of the chlorhexidine gluconate
mouthwash, consider a follow-up rinse of water. Practice tip

Movement of the lower legs, ankles and feet can be achieved
in conjunction with a gentle massage or application of moistur-
iser. Family members may wish to undertake this, giving them
Practice tip an opportunity to provide the patient with care and touch.
Performing oral hygiene with toothbrush and toothpaste in an
intubated patient and ensuring the mouth is rinsed well may
be assisted by the use of a dental sucker, which is flexible. This ASSESSMENT OF BODY POSITIONING
disposable device attached to a continuous suction system can Body positioning assessment is based on the goals of
be positioned in the mouth to aid in the continual removal of nursing care. First, a risk assessment is made and those
fluids while brushing and rinsing is performed. The dental patients at highest risk of complications related to their
sucker can also be used for continuous oral suction in patients position are those who are unable to move for long
56
with excessive saliva. periods, for whatever reason. For example, unstable
patients whose status is compromised when they are

Essential Nursing Care of the Critically Ill Patient 111

moved, patients who are in critical care for a long time, assessment, which should include a visual and physical
elderly and frail or malnourished patients, and patients assessment of all limbs and joints. Provided there are no
who are unable to move themselves (e.g. due to sedation, contraindications, function should be stimulated by
trauma, surgery or obesity) are all at risk. Batson et al. regular passive then active movements of all limbs and
identified several significant risk factors: patients receiv- joints to maintain both flexibility and comfort (see
ing adrenaline and/or noradrenaline infusions; patients below).
with restricted movement; and diabetic and unstable
57
patients. However, even previously fit patients who
experience a critical illness can develop severe limitations
in their mobility. The common short- and long-term Practice tip
complications of immobility are pressure ulcers, venous From the perspective of patient comfort, even small re-
thromboembolism and pulmonary dysfunction, each of adjustments in positioning may be advantageous, and often
which carries a significant co-morbidity. 56 can be made without much effort by the nurse or disturbance
to the resting patient. Most electric beds provide for adjust-
POSITIONING AND MOBILISING PATIENTS ments to the backrest angle, knee bend and bed tilt and adjust-
Positioning the patient to achieve maximum comfort, ments can be easily made. In addition to comfort, these
therapeutic benefit and pressure area relief and employ- adjustments will aid in pressure changes between re-positioning
ing active and passive exercises to maintain muscle and of the patient.
joint integrity and progress to regaining mobility are
important nursing activities. Provided there are no spe-
cific contraindications, the immobile patient should be
positioned with the head raised by 30 degrees or more,
58
as research has demonstrated that it improves mortality Practice tip
59
and helps reduce ventilator-associated pneumonia.
When combined with thromboembolic pro phylaxis, When planning to reposition the patient, ensure that there are
gastric ulcer prophylaxis and daily sedation assessment, enough staff to give the patient a feeling of security during the
ventilator-associated pneumonia may be reduced by procedure and that all the patient’s devices (e.g. IV lines) are
59
around 45%. Good body positioning and alignment managed. Check that all devices are placed to accommodate
helps prevent muscle contracture, pressure ulcers and the repositioning before you begin to move the patient.
unnecessary pain or discomfort for the patient. 60,61
Mobilisation for the critically ill patient can be described
as a graduated increase in range of activity from position- Active and Passive Exercises
ing, passive movement, sitting upright in bed, sitting in It takes only seven days of bed rest to reduce muscle mass
a chair to actually ambulating. 49-51,53 Stiller describes a by up to 30%, and physical activity is essential to healthy
64
62
range of safety factors that need to be considered prior to functioning and beneficial for the cardiovascular system.
54
mobilising the critically ill patient, which fall into two Active exercises are those that can be performed by the
groups; those specific to the patient and their physical patient with no, or minimal, assistance. Passive exercises
and physiological condition, and those extrinsic to the are performed when patients are either too weak or inca-
patient such as the environment, staffing and patient pable of active exercise. Exercises can be employed to help
devices attached. Creating an individualised mobility the recovering patient develop power and regain func-
plan which can be adapted according to patient assess- tion, to assist in venous return and maintain the normal
ment and general health progress, will optimise early sensation of movement. They should be performed at
64
movement and mobilisation. 53,54,62,63 least daily. Passive exercises put the main joints through
their range of movement, which helps reduce joint stiff-
Regular musculoskeletal assessment should be made,
focusing on the patient’s major muscles and joints and ness and maintain muscle integrity, preventing contrac-
the degree of mobility. Table 6.5 offers a simple guide to tures. Shoulders, hands, hips and ankles are particularly
64
at risk of stiffness and muscle contracture. It is impor-
tant, however, to ensure that joints and muscles are not
overstretched, as this is painful for patients and can cause
permanent injury. Splints may be used when the patient
64
is resting, to maintain joints in a neutral position. The
TABLE 6.5 Musculoskeletal assessment physiotherapist’s advice should be sought regarding the
correct range of movement and the frequency of passive
Muscles and joints Mobility exercises. This is particularly important for burn-injured
patients. Concern has been expressed about the effects of
● Power/strength ● Degree of independence limb movements on head-injured patients; however,
● Range of movement ● Need for assistance 65
● Symmetry ● Adherence/compliance with Koch et al. detected no significant cardiovascular or
● Tenderness and pain physiotherapy/mobility neurological changes during passive exercises in neuro-
● Inflammation, swelling, regimen surgical patients, and Brimioulle et al. found no detri-
65
wasting ● Need for planned rest periods mental effects on cerebral perfusion or intracranial
● Use of splints or collar 66
pressure (ICP), whether the ICP was raised or not.

112 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Changing Body Position to fully consider the individual needs of patients: they
Mobility is defined as the ability to change and control may have a history of back or neck problems, and the
67
body position. The complications of immobilisation in selective use of soft or firm pillows and mattresses may
critically ill patients are well documented, and include be relevant. Pillows can optimise the patient’s position so
decubitus ulcer, venous thromboembolism and pulmo- that the shoulders and chest are squared, and may reduce
nary dysfunction such as atelectasis, retained secretions, the work of breathing for patients with chronic airways
42
56
pneumonia, dysoxia and aspiration. The routine stan- disease. Some pressure-relieving mattresses have an
dard for immobilised patients in ICU is 2-hourly body adjustable pressure control, which can be changed accord-
42
repositioning, although this does not always happen, ing to pressure relief assessment and patient comfort.
56
and the optimal interval for turning critically ill patients When patients are positioned lying on one side, consid-
68
is unknown. In addition to providing pressure relief, it eration should be given to their feeling of security; for
is recommended that the patient’s position be changed example, ensuring that they are well supported by pillows
often to ensure comfort, relaxation and rest, to inflate and the bed rails are raised. Provided cerebral perfusion
both lungs, improve oxygenation and help mobilise pressure is maintained above 50 mmHg, even severely
69
66
airway secretions, to orient the patient to the surround- head-injured patients can be moved safely, however it
ings and for a change of view, and to improve circulation is important to maintain the neck in alignment to
50
to limbs through movement. The frequency of body promote venous drainage (see Chapter 17), and for those
repositioning should be determined according to the with spinal injuries, log-rolling may be required (see
patient’s pressure ulcer risk (preferably using one of the Chapter 17).
assessment tools described below), clinical stability and
comfort. Pressure Area Care
The prevalence of pressure ulcers in an ICU ranges from
Good body alignment helps prevent pressure points, con- 5% to 18% and the risk of developing a pressure sore
72
tractures and unnecessary pain or discomfort for the is cumulative: 5% risk after 5 days; 30% risk after 10 days;
60
patient. The nurse caring for the immobile critically ill and 50% risk after 20 days in the ICU. Pressure area risk
72
patient is most often responsible for determining patient for critically ill patients can be attributed to their immo-
70
positioning. Here, careful consideration should be given bility, lack of sensory protective mechanisms, suboptimal
to factors (outlined in Table 6.6) such as haemodynamic tissue perfusion and environmental factors that cause
71
and cardiopulmonary responses of the patient, the pressure and friction. The commonest locations for
42
timing and method of positioning patients, and whether pressure ulcers are the sacrum, the heels and the head.
72
there are any restrictions on movement. It is important
Significant risk factors include the age of the patient, the
number of days since admission, malnutrition, 42,49 and
delays in the use of pressure-relieving mattresses. 72,73
Pressure risk assessment tools can help nurses identify
at-risk patients. However, it is unusual for a patient in
42
TABLE 6.6 Factors to consider when positioning critical care to be assessed as low-risk. There are several
patients pressure area risk assessment tools available such as
Braden score and the revised Jackson/Cubbin pressure
67
Factors Comments risk calculator (Table 6.7) that was designed specifically
74
Haemodynamic ● Placing patients in the left lateral for use in ICU and provides an awareness of the many
and position can cause a (usually harmless)
cardiopulmonary fall in oxygenation for a few minutes
responses
Timing ● Position the patient to avoid clashes
with treatment/investigations such as
chest physiotherapy or chest X-ray TABLE 6.7 Components of the revised Jackson/Cubbin
● Consider the need for the patient to pressure area risk calculator 74
rest
Method ● The need to use lifting devices Risk assessment
● The availability of staff to perform a categories Scoring
safe manoeuvre
● The placement of pillows to support ● Age ● Score range = 12–48.
limbs; to facilitate both comfort and ● Weight/tissue viability ● One point is deducted for each of
respiratory efficiency ● Past medical history the following:
● Use of bed adjustments to create ‘chair’ affecting condition ● The patient has spent time in
positions to prepare patients to sit out ● General skin condition surgery/scan in the past 48
of bed ● Mental status hours.
● Mobility ● The patient has received blood
Restrictions on ● The need for spinal alignment ● Haemodynamics products.
positioning ● Cerebral injury ● Respiration ● The patient is hypothermic.
● Haemodynamic instability ● Oxygen requirements ● A lower score indicates higher
● Respiratory compromise ● Nutrition risk.
● Access to devices for therapies ● Incontinence ● A score of <29 indicates high risk.
● Body size ● Hygiene

Essential Nursing Care of the Critically Ill Patient 113

factors that need to be considered and monitored prior
to and during procedures for pressure prevention. TABLE 6.8 Risk of pressure sores from commonly used
Skin assessment for pressure should be scheduled at least equipment
daily and include a review of pressure relieving devices
for effectiveness or requirement for change. Skin assess- Risk factor Comments
ment should include testing for blanching response
and checking for areas of oedema, induration, redness or Endotracheal tubes The ETT should be repositioned from one
corner of the mouth to the other on a
(ETTs)
localised heat. 42 daily basis to prevent pressure on the
same area of oral mucosa and lips. Care
Pressure ulcer prevention practices include alternating the should also be taken when positioning
use of pressure-relief mattresses, low-pressure mattresses and tying ETT tapes: friction burns
and air-flow mattresses. 42,73 For bariatric patients (usually may be caused if they are not secure;
those heavier than 150 kg), specialist beds and mattresses pressure sores may be caused if they are
are required. too tight (particularly above the ears
and in the nape of the neck). Moist
Intensive care patients are at risk of pressure ulcers and tapes exacerbate problems and harbour
injury from a number of devices in everyday use, such as bacteria.
endotracheal tubes and blood pressure cuffs (see Table Oxygen saturation Repositioning of oxygen saturation probes
6.8). Close attention to detail with frequent observation probes 1–2 hourly prevents pressure on
of the patient, the patient’s position, and the presence potentially poorly perfused skin. If using
ear probes, these must be positioned
and location of equipment is required to prevent skin on the lobe of the ear and not on the
damage. It is important to remove aids such as compres- cartilage, as this area is very vulnerable
sion stockings and cervical collars to assess the skin. Vul- to pressure and heat injury.
nerable patients, such as those with poor tissue perfusion, Blood pressure Non-invasive blood pressure cuffs
anaemia, oedema, diaphoresis and poor sensory per- cuffs should be regularly reattached and
42
ception can develop pressure ulcers relatively quickly, repositioned. If left in position without
and pressure ulcers caused by equipment are entirely reattachment for long periods of time
they can cause friction and pressure
avoidable. damage to skin. Care should be taken
All pressure points and any pressure ulcers should be to ensure that tubing is not caught
under the patient, especially after
monitored closely. The key areas of monitoring are iden- repositioning.
tified in Table 6.9, and it is important to use standardised
methods to objectively assess pressure ulcers and their Urinary catheters, The patient should be checked often to
ensure that invasive lines are not
central lines and
response to therapy. If a patient develops one pressure wound drainage trapped under the patient. In addition
ulcer, there is a good chance he/she could develop to causing skin injury, they may function
another. Nursing intervention includes the placing of ineffectively.
patients in positions that avoid pressure on the affected Bed rails Limbs should not press against bed rails;
area(s), employing measures such as good fluid manage- pillows should be used if the patient’s
ment to improve tissue perfusion, reducing the risk of position or size makes this likely.
infection and promoting tissue granulation with the use Oxygen masks Use correct-size mask and hydrocolloid
of appropriate dressings. protective dressing on the bridge of the
nose to assist with prevention of
The International NPUAP–EPUAP Pressure Ulcer Classi- pressure from non-invasive or
42
fication System grades pressures ulcers as follows: continuous positive airway pressure
masks, especially when these are in
● Stage I: Non-blanchable redness of intact skin constant or frequent use.
● Stage II: Partial thickness skin loss or blister
● Stage III: Full thickness skin loss (fat visible) Splints, traction Devices such as leg/foot splints, traction
and cervical
and cervical collars can all cause direct
● Stage IV: Full thickness tissue loss (muscle/bone collars pressure when in constant use and
visible) friction injury if they are not fitted
properly. ICU patients often have rapid
The use of standardised tools to both assess pressure risk body mass loss (especially muscle)
and stage pressure ulcers is vital to effective continuity of following admission, so daily
care. Treatment of pressure ulcers is complex and based assessment is required.
on individual patient factors, however the main issues
include:

● protecting tissue from further damage with pressure Practice tip
re-distribution techniques
● preventing infection either localised or systemic by It is worthwhile knowing the key features of the beds and mat-
closely observing the ulcer for signs of infection such tresses commonly used in your area so that you can use them
as friable, oedematous, pale or dusky tissue effectively to match patient requirements for bed functions,
● aiding wound healing such as use of negative pressure bed type (e.g. bariatric suitability) and pressure prevention (e.g.
wound therapy for deep ulcers or foam and alginate high, medium or low risk mattress systems).
dressings to control heavy exudate. 42

114 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

around 10% of hospital deaths in Australia. 80,82 Patients
TABLE 6.9 Monitoring pressure ulcers with VTE may also develop post-thrombotic syndrome
where tissue injury occurs leading to pain, paraesthesia,
Factor Actions pruritis, oedema, venous dilatation and venous ulcers. 79,81
Size ● Objectively assess length, width and It is important to consider the individual patient (age,
depth. BMI) and their history (previous VTE, coagulation disor-
Stage/grading ● Use a standardised measure to grade the ders) along with their current condition whether it be
ulcer (e.g. International NPUAP & EPUAP surgical or medical and features of their treatment (immo-
Pressure Ulcer Classification System). bilisation) when determining risks for VTE. 80,81,84-86 Both
Documentation ● Note the absence/presence/location of the risk assessment and the patient’s current condition
pressure ulcers on admission and will determine the most appropriate VTE prophylaxis
discharge. strategy. 80,81 Prophylaxis consists of a combination of
● Keep a record of nursing interventions pharmacological and mechanical interventions that may
and treatments used to treat pressure
ulcers. be used together or separately according to the degree of
risk for VTE and/or contra-indications to particular thera-
Treatment ● Monitor response to therapy by pies. The use of combined therapies is supported by
assessing the size and stage/grade of 80,84,86
the pressure ulcer on a daily basis. recent reviews and guidelines. It is important to be
guided by current best evidence in choosing the most
Observing other ● Dependent areas of the body are appropriate prophylaxis regimen for your patient. The
sites susceptible: sacrum, heels, back of the
head, hips, shoulders, elbows, knees. NHMRC Clinical practice guideline for the prevention of
● Areas of the body where equipment is venous thromboembolism (deep vein thrombosis and pulmo-
causing pressure are susceptible: nose, nary embolism) in patients admitted to Australian hospitals
80
ears, corners of the mouth, fingertips. provides a comprehensive guide to risks and manage-
● Areas of the body where tissue perfusion ment relating to VTE for critical care in Australia.
is poor are susceptible: extremities.
Low molecular weight heparin or unfractionated heparin
is the most common pharmacological therapy prescribed
Rotational Therapy in Australia, while other medications will be prescribed
for patients according to individual factors. 80,87 Special
Continuous Lateral Rotation Therapy (CLRT) or Kinetic consideration of an appropriate regimen for pharmaco-
bed therapy is an intervention in which the patient is logical prophylaxis will need to be given to patients with
rotated continually, on a specialised bed, through a set renal and hepatic impairment. Heparin-induced throm-
87
number of degrees; it helps to relieve pressure areas and bocytopenia (HIT) may develop in some patients so as
88
can significantly improve oxygenation. 75-77 Continual with all heparin therapy, close monitoring of the patient’s
lateral rotational therapy may reduce the prevalence of platelet count and assessing for signs of bleeding such as
ventilator-associated pneumonia in patients requiring bruising or haematuria will form part of the nurse’s role
76
long-term ventilation. Appropriate evaluation of the in managing VTE prophylaxis.
benefits and suitability of the patient for CLRT should be
undertaken by the team and the therapy implemented In principle, it is advised that graduated compression
75
according to local protocols. In implementing this stockings are used for all general, cardiac, thoracic and
therapy, the goal is to achieve continuous rotation through vascular surgical patients until full mobility is achieved
the maximum angle that the patient tolerates for 18 irrespective of pharmacological prophylaxis. 80,86 Mechan-
hours per day. 75,78 ical prophylaxis is provided through a range of graduated
compression stockings and various pneumatic venous
Venous Thromboembolism (VTE) Prophylaxis pump or sequential compression devices. 80,81,84,86,89,90 It is
important to make sure that the relevant devices are
Deep vein thrombosis (DVT) and pulmonary embolism
(PE) are separate conditions collectively referred to as fitted correctly and monitored closely. Comparisons
venous thromboembolism (VTE). 79,80 DVT is a blood clot between a number of pneumatic pumps have been
88-90
in a major vein of the lower body, i.e. leg, thigh, pelvis, studied with all displaying relative effectiveness. The
which causes disruption to venous blood flow and is availability of battery-operated sequential compression
often first noticed by pain and swelling of the leg. The devices can assist with the continuous application of the
blood clot forms due to poor venous flow, endothelial therapy during patient transports away from their bedside,
injury to the vein or increased blood clotting which may such as to the imaging department for radiological
90
be caused by trauma, venous stasis or coagulation disor- procedures.
81
ders. Pulmonary emboli occur when a part of a throm- Along with pharmacological and mechanical venous
bosis moves through the circulation and lodge in the thromboembolism prophylaxis, maintaining patients’
pulmonary circulation. VTE is a major risk factor for hos- hydration and implementing early mobilisation are key
pitalised patients 80-83 in general and critically ill patients components of care in preventing VTE. 79,80,84 Rauen et al.
79
in particular, due to blood vessel damage, coagulation describe the most common reasons cited for lack of
79
disorders and limited mobility leading to venous stasis. proper VTE prophylaxis as being lack of knowledge
Further, around 50% of patients with DVT will also suffer among healthcare providers and under-estimation of risk
a pulmonary embolism, which can be fatal causing of VTE along with over-estimation of the potential risk of

Essential Nursing Care of the Critically Ill Patient 115

bleeding from prophylaxis. Given the risks of VTE for of a protocol improves bowel care. Rectal examination
91
critically ill patients, it is clearly important that nurses should be performed within 24 hours of ICU admission
contribute to lowering risks for their patients by knowing and it should also be undertaken if the patient has not
92
the range of risk factors for their patients, along with the had their bowels open for three consecutive days. If the
appropriate pharmacological prophylaxis that may be bowels have not been opened during this period, action
96
prescribed, how to appropriately implement and manage should be taken. For some patients in whom defecation
the mechanical prophylaxis devices and most impor- is problematic, it may be appropriate to objectively assess
tantly facilitate the early mobilisation of the patient. the quality of faecal stools using a tool such as the Bristol
stool form scale, which uses a 7-point grading system to
BOWEL MANAGEMENT assess stool consistency (see Table 6.10). 97,98
Although bowel care is an essential aspect of nursing care ESSENTIAL BOWEL CARE
in the critical care setting, there is little research evidence
in this area. Good bowel care promotes patient comfort Nursing care is based on managing privacy and embar-
and reduces the risks of further problems such as nausea rassment, increasing exercise where possible, ensuring
and vomiting. The prevention of constipation, which can adequate fibre and fluid in the diet, reducing unnecessary
occur when patients are immobile or have reduced gut use of drugs that cause constipation, and appropriate use
93
motility or a poor dietary intake, is important as it may of laxative agents. Where bowel care is concerned, it is
contribute to the exacerbation of other conditions, such always appropriate to first explain to patients what is to
as myocardial infarction, congestive cardiac failure, stroke be done, and to gain their consent if they are conscious.
and head injury. 91,92 Enteral feeding is often cited in the Constant reassurance is important so that patients feel
literature as a cause of diarrhoea, but poor gastric fluid safe and secure in the knowledge that their privacy will
93
intake causes constipation, and improved gut motility be maintained to the greatest degree possible. This is
decreases the risk of aspirations. The prevention of con- sometimes difficult when more than one nurse is required
stipation is particularly important for patients with high to position a patient for bowel assessment, defecation or
cervical spinal injuries, as if left untreated it may cause cleansing. However, it is always important to explain to
potentially fatal autonomic dysreflexia. 94 patients why more than one person is necessary and to
reassure them that they will be exposed for the minimum
Bowel care can also be one of the most distressing aspects period necessary.
of nursing care, from a patient’s perspective. Often
patients find bowel care to be awkward and embarrassing, Peristaltic movement of the gut is stimulated by exercise.
which may be particularly intensified when they feel that Although difficult in the intensive care setting, many
they are not in control of their own body. Sensitive patients are awake, and even those who require sedation
nursing care that respects the dignity of the patient is should be sedated with the minimal amount necessary
paramount. for their safety, as this will enable some degree of move-
ment. Promoting movement, especially voluntary move-
BOWEL ASSESSMENT ment, is helpful as it will improve gut motility.
Initial bowel assessment should be undertaken to deter- Diet and Fluids
mine the patient’s usual bowel habits, as less than 10%
of the population have a daily bowel action, and for 1% Diet and fluids are two important considerations in
92
of the population less than three times a week is normal. maintaining normal bowel function. Ensuring the appro-
‘Normal’ bowel function should be regarded as at least priate administration of fluid and an adequate dietary
96
95
twice a week. In general, older patients are more suscep- fibre intake helps to prevent constipation. Enteral
91
tible to constipation. feeding increases faecal bulk and provides gastric fluid,
Gut function should be assessed at the start of each
nursing shift (see Box 6.2). Several authors 91,92,96 have
101
developed bowel care protocols for intensive care patients.
93
The results of the McKenna et al. study suggest that use
TABLE 6.10 Bristol stool form scale
Grade Description
0 No bowel movement
1 Separate hard lumps; like nuts; hard to pass
BOX 6.2 Assessment of gut function
2 Sausage-shaped but lumpy
● Observation of nasogastric aspirate volume 3 Like a sausage but with cracks on the surface
● Visual inspection and palpation of abdomen, noting any
tenderness, pain or distension 4 Like a sausage or snake but smooth and soft
● Recording the frequency, nature and quantity of bowel 5 Soft blobs with clearcut edges; easily passed
actions 6 Fluffy pieces with ragged edges; a mushy stool
● The presence or absence of bowels sounds
7 Watery; no solid pieces; entirely liquid

116 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

which helps to maintain gut motility. Chapter 19 con-
tains an in-depth discussion on the principles of enteral Practice tip
feeding.
If a rectal tube is considered necessary, then use of a commer-
Drugs cial product consisting of a specific rectal tube and drainage
system is advised, rather than an ‘adapted version’, which may
The use of sedatives is often an ascribed cause of constipa-
tion in critically ill patients. This is not due to their direct inadvertently cause damage.
effect, but due to the subsequent immobility of patients
when sedatives are used. Opiates, which are often used
to control pain, slow propulsive gut contraction. The Practice tip
main drugs that cause constipation in critical care settings
are analgesics, anaesthetic agents, anticonvulsants, diuret- When undertaking bowel assessment you should also consider
91
ics and calcium channel blockers. While it is difficult the patient’s normal diet and any laxatives routinely taken, as
to avoid giving these drugs, their judicious use in this information may influence any bowel regimen developed
tandem with other preventive measures will help for the patient.
avoid constipation.

Constipation URINARY CATHETER CARE
91
Although there is no consensus, constipation may be Urinary catheters are inserted into most critically ill
defined in general as decreased frequency of defecation patients, and are the commonest cause of infection in the
99
or bowel movements, with a hard, dry stool. Non- ICU. In principle, urinary catheters should be inserted
103
pharmacological methods to reduce constipation include only when deemed clinically necessary, and should be
exercise or moving, increasing fluid intake, and adding removed as soon as they are no longer required clinically.
99
dietary fibre. These means should be implemented rou- However, most critically ill patients require accurate moni-
tinely before the need to use laxatives arises. There are toring of their urinary output and fluid balance, and a
many types of laxatives available, which can be given to catheter is required for this reason. There are a number of
104
prevent or treat constipation. Bulk-forming agents work possible alternatives to urinary catheterisation, such as
by increasing faecal size; stimulants, such as senna, intermittent catheterisation, suprapubic catheterisation,
increase peristalsis; and osmotic agents draw fluid into use of a male/female urinal or penile sheath and/or incon-
the gut. Stimulant laxatives should not be given with tinence pads, although often these are not suitable for
105
91
faecal impaction, which should be treated using enemas. critically ill patients. Because the practice of urinary cathe-
In general, existing protocols advise that treatment of terisation is so common, catheter care can sometimes be
constipation should commence with senna administra- relegated to a low priority. The consequences of inadequate
tion. If senna is ineffective after 2–3 days, lactulose should catheter care can be distressing and detrimental to the
be commenced. 91,92,96 patient, resulting in inflammation, infection and injury.
Diarrhoea ASSESSMENT: URINARY CATHETERISATION

Diarrhoea can be a major problem for intensive care Following assessment indicating that a urinary catheter is
patients, and in severe cases may lead to electrolyte imbal- required, its size and type should be determined. In addi-
ances, dehydration, malnutrition (see also Chapter 19) tion to their primary purpose of urine drainage, urinary
and skin breakdown. Furthermore, it can be very distress- catheters may be used to monitor temperature and assess
ing for the patient, who may also suffer from distension, intra-abdominal pressure which may affect catheter
nausea and cramp-like pain. Investigations should be choice. Catheters are made from several different types of
implemented to determine the cause of the diarrhoea and material, which have varying properties, and the choice
the patient should be managed with appropriate precau- of catheter often depends on an estimation of how long
tions to prevent cross contamination if the cause is infec- it will be required. Catheters are classified as either short-
tious. If laxatives are being given they should be stopped, or long-term. Short-term catheters should be changed
and a stool specimen should be obtained for microbio- after 14–28 days, according to the manufacturer’s guide-
logical examination. Antimotility drugs may be used, lines, whereas long-term catheters may be left in place
except with bloody diarrhoea or proven infection with E. for up to 12 weeks. The minimum length of a male
106
Coli. 96,100 Appropriate re-hydration should be imple- catheter is 380 mm, and for a female it is 220 mm. 106
100
mented. If patients are being fed enterally there may be
a reduction in episodes of diarrhoea if fibre-enriched feed The general rule is to use the smallest size necessary that
101
107
is used. Fecal containment devices should be used in will drain the contents of the bladder, although narrow-
severe cases of diarrhoea in conjunction with all other bore tubes flex easily, which can be problematic in male
102
measures to support the patient’s comfort. The patient catheterisation where the urethra rounds the prostate
should be assessed for suitability for using the inconti- gland. Larger-diameter catheters may be required to drain
107
nence system as per the manufacturer’s guidelines. An haematuria and clots. All procedures involving the
appropriate bowel therapy regimen and monitoring of catheter and drainage system should be documented in
these systems should be implemented to optimise the clinical notes, including size and type of catheter,
functioning. balloon size and the date of insertion.

Essential Nursing Care of the Critically Ill Patient 117

ESSENTIAL NURSING CARE: URINARY solution should be kept minimal, as it is a potentially
CATHETERISATION irritant chemical that can cause tissue damage: 50 mL is
Catheter insertion and maintenance should be under- as effective as 100 mL, and two sequential 50 mL wash-
taken by people adequately trained in the procedures. outs are more effective at removing encrustation than one
109
Aseptic technique should be observed, and hands should 100 mL washout.
be washed immediately before and after catheter inser- Critically ill patients should be provided with appropriate
tion and any manipulation of the catheter or drainage information about their catheters and drainage system,
system. Protective clothing should be used in accordance according to their needs and ability to understand. The
with Standard Precautions guidelines (see Infection control drainage system should be simple to operate with one
later this chapter). hand, easy to position, and the tap should have an open–
close device. Contamination of the outlet must be avoided
The urine drainage system should be sterile and continu- and alcohol-based sprays may be used to decontaminate
ously closed with an outlet designed to avoid contamina- the outlet (inside and outside) before and after emptying.
tion. It should have a sample port for taking urine An aseptic technique and sterile equipment must be used
samples. If possible and appropriate, patients should be when taking a urine sample via the sample port. The
given a choice of system appropriate to their needs: for sample port should be cleaned with an alcohol wipe for
example, a shorter drainage tube with a leg-bag may be 30 seconds before and after sampling. Urine samples
more comfortable for a patient who is mobile.
should be taken on clinical need and must be refrigerated
Catheter Maintenance if more than 1 hour is expected to elapse before the speci-
men reaches the laboratory.
The continued need for a urinary catheter should be
assessed on a daily basis. Daily reminders by nursing staff The whole drainage system should be maintained with
to doctors results in shorter duration of catheter insertion, patient comfort in mind, and care should be taken to
103
with a lower associated infection rate. The introduction ensure that the patient is not lying on the drainage tube,
of criteria that enable registered nurses to remove cathe- which can cause pressure sores and blockage. Further-
ters without a doctor’s order may result in a significant more, the catheter itself should be positioned so that it
reduction in catheter-related infections. Penile meatal is not pulling on the urethra or kinked. The drainage bag
care with soap and water 104,106 should be performed at should be kept below the level of the bladder at all times
appropriate intervals for patient comfort and to keep the to maintain an unobstructed flow of urine, and it should
meatus free of encrustation and contamination. Cleans- be emptied into a disinfected or single-use container. The
ing with antiseptic solution is not recommended and can drainage bag should be changed according to the manu-
lead to multi-resistant organism infection. facturer’s instructions, which is usually in the range of
5–7 days. In addition, it should be replaced if it is leaking
Urinary catheters should be changed according to clinical or whenever the catheter is changed.
need and with regard to the manufacturer’s guidelines,
and the closed drainage system should be broken only
for limited, clearly defined clinical reasons. Bladder
washout or irrigation should be performed only for a Practice tip
specific clinical reason, for example catheter blockage or
high risk of blood clot formation, and should not be Using a catheter support bandage on the leg to secure the
considered as routine practice. A variety of solutions may urinary catheter can assist with comfort by minimising tension
be used for washouts (see Table 6.11) although research and irritation from catheter movement, promote effective
107
in this area is limited. The volume of bladder washout drainage and in the restless patients may prevent accidental
108
catheter removal as well.
TABLE 6.11 Solutions used for bladder washouts
BARIATRIC CONSIDERATIONS
Solution Indication Obesity is known to be a major health issue around
Sodium For the removal of small pieces of debris. Effect the world. While many bariatric patients will present to
chloride 9% is purely mechanical. May be used as hospital with various health issues, obesity has its own
required. physiological impact to be considered also, such as
Citric acid Used to dissolve encrustations. Aids impaired chest expansion and respiration from a large
3.23% reacidification of urine. May be used up to abdomen or insulin resistance related to altered glucose
(Solution G) twice daily. metabolism. 110,111 Close glucose monitoring regimens
Citric acid 6% Used to unblock an encrusted catheter. Can be should be implemented and appropriately calculated
(Solution R) used before removal to reduce trauma from dosages for medications be prescribed. Adapted tech-
encrustation. May be used up to twice daily. niques to enhance patient assessment may be required,
Chlorhexidine Used to reduce bacterial growth in the bladder, such as auscultating over the left lateral chest wall to hear
0.02% though research does not support its use. heart sounds while the patient is positioned towards their
May lead to the development of resistant left side or using a thigh or regular blood pressure cuff
organisms.
on the patient’s forearm. 110

118 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Studies have found that persons who are obese contend experienced, such as during re-positioning, if the activity
112
with a negative bias within a social context but this is not arranged competently and with sensitivity.
same negative bias from health professionals including VTE prophylaxis in bariatric patients is vital especially for
nurses may then interfere with their ability to obtain those patients having bariatric surgery. Routine prophy-
quality healthcare. 112-114 According to Susan Bejciy-Spring, laxis is recommended with weight adjusted dosing
the key to providing quality, patient-centred, sensitive of medications. 81,111 Combining pharmacological and
care to the bariatric patient is R-E-S-P-E-C-T: Rapport, mechanical prophylaxis is recommended for this high
Environment/Equipment, Safety, Privacy, Encourage- risk group. The application of leggings or sleeves for
114
ment, Caring/Compassion and Tact. Simple things sequential compression devices or pneumatic venous
such as an appropriately sized gown and suitable bed pumps can often be easier than applying graduated com-
linen which provide the patient with adequate covering pression stockings in any patient when they are supine in
are often not well-organised for this patient group, unless bed. Care must be taken with measuring the limb to
the nurse takes the time to arrange specific supplies if they obtain the correct size legging or stocking. Careful moni-
are not routinely available.
toring of the limb for signs of skin deterioration from
Sedation in the bariatric patient needs to be carefully moisture, or pressure from an ill-fitting legging, sleeve or
managed to avoid the resultant risk of respiratory stocking must be undertaken diligently in the bariatric
failure and need for ventilation. Reducing narcotic usage patient. The insertion of a removable inferior vena cava
81
through use of combinations of other analgesia along (IVC) filter as a component of pulmonary embolism pro-
with sedatives will also reduce risk for respiratory failure. phylaxis for patients undergoing bariatric surgery may
115
Bispectral index monitoring can be used to assist in occur in some institutions. 111
the titration of sedations during procedures where levels
of sedation that eliminates awareness and recall is The post-operative management of the bariatric patient
necessary. 115 will include nutrition to support tissue repair. The use of
postpyloric enteral nutrition may be of benefit in reduc-
The use of arterial monitoring rather than non-invasive ing the risk of aspiration in the bariatric patient, as these
blood pressure measurements for patients receiving patients often experience post-operative vomiting and
titrated vaso-active infusions should be considered, nausea. 115
because of the difficulty in obtaining accurate readings if
the cuff is not sized or positioned correctly. Use specific INFECTION CONTROL IN THE CRITICAL
bariatric equipment and techniques to move patients CARE UNIT: GENERAL PRINCIPLES
safely for both the patient and the staff involved. It is
important to be aware of the weight capacities of various Effective infection control is vital in the critical care
facilities, such as lifts and equipment, that may be setting to prevent further health risks to critically ill
required in the care of the bariatric patient. patients already compromised by their disease or trauma
(Box 6.3). Critically ill patients often require multiple
Overweight patients can be challenging in any setting,
and it is important to consider the health and safety of invasive devices and therapies to manage their illness and
the staff involved in lifting and moving patients. Equally these increase the potential risk for infection to the
important is maintaining the patients’ dignity and feel- patient. While using therapeutic medical devices is often
ings of safety and minimising their self-consciousness vital to the management of the patient, they are not
during repositioning, irrespective of the method required. without risk. Ventilator associated pneumonia (VAP),
Lifts and hoists and other equipment that are designed catheter associated urinary tract infections (CAUTIs) and
for heavier people should be used. 116,117 A well-thought- central line associated bacteraemia (CLAB) are all aligned
out strategy by an inter-disciplinary group can work with invasive device use and form a significant source of
through the local issues within a hospital or unit and healthcare acquired infections (HAIs) within critical
119
produce a Bariatric Kit, containing a range of equipment care. Critical care staff themselves need to protect
appropriate to the needs of the bariatric patients in against contracting infections while providing care for
various settings including the ICU. 117 their patients.
When patients are admitted to critical care it is impossi-
A major concern in the ICU is the positioning of the
morbidly obese patient with respect to airway manage- ble to identify whether or not they are newly colonised
ment and oxygenation. Boyce et al found no differences with bacteria, or are carrying an infection, without further
in the difficulty of airway management when patients investigation. Standard Precautions are applied in the
were in the 30-degree reverse Trendelenburg (head up, management of all patients regardless of the reason for
feet down), supine-horizontal, or 30-degree back-up their admission. Standard Precautions include hand
118
position. However, when patients were positioned in hygiene, respiratory hygiene and cough etiquette, the use
the reverse Trendelenburg position, their oxygen satura- of appropriate personal protective equipment, safe han-
tion dropped the least and took the shortest time to dling of sharps, waste and used linen, appropriate clean-
recover. Consult with the patient about techniques that ing and environmental controls, appropriate re-processing
work for them at home when re-positioning and mobilis- of re-usable equipment and the use of aseptic non-touch
119
ing. As with all patients, bariatric patients are vulnerable techniques during procedures.
to fears and anxieties resulting from their illness, however With the advent of Influenza H1N1 outbreaks, there has
additional concerns for their physical safety may be been an emphasis on respiratory hygiene and cough

Essential Nursing Care of the Critically Ill Patient 119



BOX 6.3 Infection-control guidelines for the TABLE 6.12 Transmission-based precautions and
prevention of transmission of infectious infectious conditions
diseases in the healthcare setting 119
Transmission- Examples of infectious
● Healthcare-associated infections are those acquired in care based precautions conditions
establishments (‘nosocomial’ infections) and infections that Contact MROs : MRSA, MRGN, VRE, ESBL
occur as a result of healthcare interventions (‘iatrogenic’ Gastro-intestinal Pathogens: C. difficile,
infections). The infection may manifest after people leave norovirus
the healthcare establishment. Highly contagious skin infections
● A healthcare establishment is any facility that delivers Droplet Influenza
healthcare services. RSV, Pertussis
● Healthcare workers (HCWs) are all people delivering health- Meningococcal
care services, including students, trainees and mortuary Airborne Pulmonary TB
attendants, who have contact with patients or with blood Chickenpox (varicella), Measles (rubella)
and body substances. SARS
● Standard precautions are standard operating procedures Adapted from NHMRC Guidelines. NB: Standard Precautions apply for all
that apply to the care and treatment of all patients, regard- patients at all times
less of their perceived infection risk. They are work practices
required to achieve a basic level of infection control and are There are three types of Transmission-based Precautions
recommended for the treatment and care of all patients recommended for Australian healthcare to counteract
119
(see Table 6.13). the various infectious agents: Contact Precautions,
● Transmission-based precautions are required when stan- Droplet Precautions and Airborne Precautions (see
119
dard precautions may not be sufficient to prevent the Table 6.12) These types of precautions are applied with
transmission of infectious agents (e.g. in tuberculosis, refinement to the use of personal protective equipment,
measles, Creutzfeldt–Jakob disease). These precautions are room requirements and recommendations for visitors
tailored to the specific infectious agent concerned and specific to the mode of transmission of the organism.
may include measures to prevent airborne, droplet or Critical care nurses should be knowledgeable of both
contact transmission, and healthcare-associated transmis- local and national guidelines and protocols for Infection
sion agents. Control in order to provide safe care to all their patients.
● Transmission-based precautions are recommended for Breaks to the consistent application of Standard Pre-
patients known or suspected to be infected or colonised cautions and, when implemented, Transmission-based
with disease agents that cause infections in healthcare set- Precautions put patients at risk, especially those who are
tings and that may not be contained by standard precau- critically ill.
tions alone.
While good hand hygiene is the single most effective tool
Copyright Commonwealth of Australia in infection control, 120,121 the key components of effective
infection control are surveillance, prevention and control,
which are described in more detail below.




etiquette, which effectively means covering the mouth
with a tissue when coughing or sneezing and then imme- Practice tip
diately disposing of the tissue into waste bins, followed
by effective hand hygiene. Further Transmission-based Good hand hygiene is vital before and after all interventions
119
Precautions (previously referred to as Additional Precau- with your patients. Also there are large numbers of objects in a
tions) are implemented as required in response to suspi- single ward or unit, such as computer keyboards and door
cion (while awaiting confirmation from tests) or diagnosis handles, which are touched by many people within a day. The
of a condition in which Standard Precautions may not be movement of contaminants from inanimate objectives to
sufficient to control the transmission of microorgan- patients and the reverse are possible if adherence to good hand
119
isms. Transmission-based Precautions appropriately hygiene is not upheld. Remember the 5 moments of hand
applied to specific microorganisms disrupt their method hygiene.
of transmission to other patients, visitors and healthcare
workers. Transmission-based Precautions include con-
tinuation of Standard Precautions, the use of personal
protective equipment specific to the risk of transmission, SURVEILLANCE
individual patient equipment where possible and specific Around 25% of ICU patients are infected prior to admis-
cleaning protocols for shared equipment, placement of sion, 122 so routine screening should be undertaken to
patients in single rooms (or cohorted if appropriate) and detect the presence of bacteria. Ideally, all critically
specific air filtration or circulation and environmental ill patients will be screened for MRSA and VRE on
cleaning protocols. 119 admission. 123 Regular surveillance to identify rates of

120 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

nosocomial infection, with feedback to critical care staff,
helps to improve compliance with infection control TABLE 6.13 Preventive measures to reduce the spread
guidelines. 119,124 In the 1980s, a landmark study estab- of gramnegative infection 128
lished that hospital-acquired infection may be reduced by
around a third if surveillance and prevention programs ● Identifying the infected patient using a colour-coded plate
are implemented. 125 according to the microorganism
● Infection control notification in the patient’s records
● Hand washing with antiseptic solution before and after contact
PREVENTION with the patient
The Australian government Department of Health and ● Contact precautions using obligatory gloves and gowns during
direct patient contact
Ageing provides guidelines for infection control within ● Separation of stethoscopes, sphygmomanometers and
119
the healthcare setting (see Box 6.3). All health services thermometers for individual use
should apply these guidelines and operate within clearly ● Separation of other articles and equipment for exclusive use of the
defined infection-control procedures, which are based on patient
Standard Precautions. Although formerly referred to as ● Daily surface cleaning and disinfection with 70% alcohol
Universal Precautions and Additional Precautions, the
recent guidelines on infection control from the NHMRC
uses Standard Precautions and Transmissions-based Pre-
cautions respectively to clearly describe these levels of
119
precautions. Critical care nurses should refer to their BOX 6.4 Hand hygiene: ‘5 moments’
specific hospital infection-control policies regarding
details of procedures that must be followed. Hand Hygiene is performed:
● before touching a patient
CONTROL ● before commencing a procedure
● after a procedure or exposure to body fluids
Once an organism has been identified, the goal is to limit ● after touching a patient
its spread. Although patients may be colonised with bac- ● after touching a patient’s environment
teria, they may not be infected. Colonisation refers to the
presence of microorganisms in any amount, whereas Plus
infection means that pathological tissue injury or disease ● after the removal of gloves.
has occurred due to the invasion and multiplication of Adapted from Grayson et al. 2009 117
the microorganism. 126 Typically, surveillance measures
identify many patients who are colonised with MRSA or
VRE, and although they themselves are not infected it is
important to stop the spread of bacteria to patients more hand hygiene compliance is poor, 119,120 but it can be
vulnerable and thus more susceptible to opportunistic improved significantly if regular education programs,
infection, by implementing Transmission-based Precau- feedback and reminders are employed 119-121 such as the 5
tions. 127 In a study of multiresistant gram-negative bacte- moments for hand hygiene (see Box 6.4) created by the
120
rial infections in ICUs, several effective measures were World Health Organization (WHO) in 2009 which has
128
demonstrated, which are summarised in Table 6.13. been adopted for local implementation, such as Hand
121
Due to the vulnerable nature of critically ill patients, Hygiene Australia. Evidence has led to the current rec-
specific issues are described in more detail including: ommendation of using an alcohol based hand rub for
hand hygiene, personal protective equipment (PPE), hand hygiene unless the hands are soiled. 120,121,129 The use
multi-resistant organisms (MROs), Healthcare associated of alcohol hand rubs is associated with higher rates of
infections (HAIs), ventilator associated pneumonia (VAP) hand hygiene compliance and effectiveness although
and central line associated bacteraemia (CLAB). effectiveness is dependent on technique. 120,121,129,130


Practice tip Practice tip

When using open tracheal suctioning techniques, it is most Compliance with local protocols for surveillance, isolation and
important to ensure that the ventilator connection is not con- use of PPE for MROs and infectious conditions is vital to the
taminated during the procedure while disconnected from the management of all patients, and the safety of personnel and
tracheal tube. visitors in critical care units.



Hand Hygiene Personal Protective Equipment (PPE)
At the core of Standard Precautions is effective hand PPE may include any and all of the following: plastic
hygiene. Good hand hygiene is a simple yet effective aprons, gowns (single use or sterile), gloves (single use or
technique that reduces the spread of bacteria. It is the sterile), masks ranging from surgical to particulate filter
most effective and least expensive method of preventing N95 mask or P2 respirators and eye protection such as
120
healthcare associated or nosocomial infection. However, goggles or face shields that also protect mucous

Essential Nursing Care of the Critically Ill Patient 121

119
110
membranes of the mouth and nose. Specific sequences epidemic proportions. Multiple strains of MRSA have
have been outlined for putting on and taking off PPE, been identified, and in many studies ICUs have the
that minimise the risk of contamination. 119 highest incidence. 127 In the past decade vancomycin-
resistant Enterococcus (VRE) has become a serious health
Epidemic outbreaks of SARS occurred in Canada, China,
131
Hong Kong, Singapore and Vietnam, and it has been issue in Australia. As with MRSA, VRE transmission is
reported in over 25 countries since the WHO issued its associated with contact. Other resistant organisms found
global alert in March 2003. 132 SARS was transmitted in critical care areas include coagulase-negative Staphylo-
between patients, healthcare workers and hospital visi- coccus, Pseudomonas aeruginosa, Acinetobacter spp, and
126
tors, and large within-hospital outbreaks were associated Steno trophomonas maltophilia.
with aerosol-generating procedures such as bronchos- MRSA is endemic in hospitals throughout the world, and
copy, endotracheal intubation and the use of aerosol critical care units have a central role in its intra- and
therapy, 132 which are commonplace in critical care areas. interhospital spread. 127 Patients who are colonised nasally
In Hong Kong, more than 20% of cases were healthcare with MRSA have a significant risk of wound infection,
workers. 133 Because of the high level of morbidity and and the risk of MRSA infection is higher in patients who
mortality associated with SARS, 134 the risk to healthcare have previously been colonised with MRSA and in those
staff is considerable and during the Hong Kong SARS out- who have been admitted to hospital on a previous occa-
break, healthcare workers wore full head covers with a sion. It has been found that the longer the patient remains
visor. 135 in ICU the higher the risk of MRSA infection. 127

Previous research has demonstrated relatively low rates There are a number of methods for reducing the spread
of compliance with standard precautions, ranging from of MRSA (see Table 6.13), although not all methods may
16–44%. 136 The SARS outbreaks emphasised the need for be effective, 133 and if the organism is not identified, its
effective infection-control procedures, especially for air- spread will continue unseen. Another key component of
borne pathogens such as the SARS coronavirus (SARS- management of MROs is surveillance, such as the routine
CoV). With airborne pathogens such as Pulmonary TB or screening for MRSA and VRE of all patients on admission
SARS-CoV, Airborne Precautions 137 using N95 masks to critical care areas and on a regular basis thereafter.
(face mask with 95% or greater filter efficiency), gowns Once diagnosed, it is common practice to isolate MRSA
and gloves are implemented to reduce the spread of the patients to reduce cross-infection; however, there is recent
organism, plus the use of negative air pressure rooms and evidence that questions its necessity. 139
strict control of family visiting. 137 Additional measures
may include the use of high-efficiency bacterial filters to Healthcare Associated Infections
filter patients’ expired air, closed suction systems and Nosocomial, or hospital- or healthcare-acquired, infec-
ventilator scavenging systems. 135
tion (HAI) is a major problem in critical care that may
The more recent Influenza H1N1 pandemic alerted every- affect up to 20% of patients, with a mortality of around
one to the need for vigilance in infection control. The use 30%. 122 Critically ill patients are 5–10 times more likely
of Droplet Precautions are the main feature of infection to become infected than hospital ward patients. 126
control for Influenza, along with early testing. 138 The Multiple-drug-resistant bacteria are a worldwide problem;
Influenza outbreak also drew attention to the need for their acquisition by patients can lead to infection with
vaccinations. All healthcare workers and especially the same bacteria, 123 and multiple antibiotic therapy
126
those in critical care should be knowledgeable of the vac- encourages the proliferation of resistant organisms.
cinations that may be available to them through their The introduction of antibiotic stewardship assists in
employers and those that are recommended by local focusing on the optimal use of antibiotics. 119
jurisdictions.
Medical devices or therapies may expose the patients to
potential risk of acquiring a HAI. This risk may occur
during the insertion procedure or subsequent mainte-
Practice tip nance care of the medical device, unless appropriate tech-
niques are used. The use of an aseptic technique during
Reminder: hand hygiene is performed before putting on PPE insertion of a device is a feature of infection control,
and after removing PPE. Hand hygiene is also performed after asepsis being the elimination of pathogens. Aseptic non-
removal of gloves. touch technique (ANTT) is a format for guiding practice
in the application. 140,141 Standard ANTT involves standard
hand hygiene, a general aseptic field and non-sterile or
sterile gloves and is used for minor procedures which are
Multi-Resistant Organisms simple and of short duration, that is, less than 20 minutes.
MRO is a collective term for a number of infections from Examples of procedures would include simple wound
multi-resistant organisms. While the early diagnosis of dressings and intravenous cannulation or urinary cathe-
an MRO and immediate implementation of organism- terisation by proficient practitioners. Surgical ANTT is
specific Transmission-based Precautions is key to man- used for complex or lengthy procedures such as insertion
agement, it is true that Methicillin-resistant Staphylococcus of a central venous catheter and involves the use of full
aureus (MRSA) and extended-spectrum beta-lactamase- barrier precautions (sterile gown and gloves, face mask),
119
producing Enterobacteriaceae (ESBL-E) have reached extensive drapes and critical aseptic field. Box 6.5

122 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



BOX 6.5 Invasive device management TABLE 6.14 Strategies to prevent VAP
● Does the patient need the invasive device for effective Measure Interventions
management of their condition?
● Is the chosen device is the most suitable for the individual Infection control ● hand hygiene
measures
● active surveillance
patient, e.g. size and type of device? ● appropriate PPE when managing
● Are the healthcare professional/s trained to safely insert ventilation related devices, e.g. ETT,
and manage the device? ventilator circuits, tracheal suctioning
● Use the appropriate aseptic procedure for device Gastrointestinal ● oral hygiene
insertion. tract ● stress ulcer prophylaxis
● Follow management protocols to minimise the risk of infec- ● avoid gastric over distention
tion while the device is in situ. ● enteral nutrition
● Monitor the patient for signs and symptoms of infection. Patient position ● semirecumbent with head raised to >30°
● Review the need for the device in the management of the ● rotational bed therapy
patient daily and remove as early as possible. Artificial airway ● respiratory airway care
● avoid unplanned extubations
Adapted from NHMRC Guidelines 119 ● secure tracheal airway cuff
● inline or intermittent subglottic secretion
removal
Mechanical ● maintenance of ventilation equipment,
provides some basic points to guide management of the ventilation heat and moisture exchangers, safe
use of medical devices in critical care. removal of condensate from circuits
● minimise ventilation time
The commonest healthcare associated infections, in order ● daily assessment for readiness to wean
of incidence, are surgical sites, urinary tract, lower respira- therapy and/or extubate
tory tract and bloodstream. 142 For the critically ill patient ● non-invasive mechanical ventilation
intravascular cannulas including central venous catheters, PPE = personal protective equipment; ETT = endotrachael tube
urinary catheters, enteral or nasogastric tubes and artifi-
cial airways and ventilation are some of the healthcare
devices associated with risk. See the section on urinary
catheters for information regarding catheter-associated inconsistent reduction in ICU mortality, and there
urinary tract infections. remains concern about the promotion of antimicrobial
resistance with its prolonged use. Related information
148
Ventilator-Associated Pneumonia on respiratory failure and ventilation can be found in
Ventilator-associated pneumonia (VAP) is common in Chapters 14 and 15.
intensive care and usually occurs within 48 hours of ini-
tiating ventilation. 143 There are several measures that Central Line Associated Bacteraemia
should be taken to reduce VAP. 144 A number of strategies Bloodstream infection is a serious complication often
that are effective in helping to prevent infection 143 are caused by intravascular catheters, particularly those that
identified in Table 6.14, of which the simplest and most terminate close to the heart. 149 The use of central lines is
effective is raising the head of the bed. Effective analgesia common in critical care areas. Catheter-related sepsis is
and minimising sedation while avoidance of muscle- defined by the International Sepsis Forum as at least one
relaxant medications along with early mobilisation are peripheral positive blood culture plus at least one of the
some of the other strategies which may contribute to the following: a positive catheter tip culture, a positive hub
reduction of VAP. Provided a heat and moisture exchanger or exit-site culture, or a positive paired central and periph-
(HME) is used, it is not necessary to routinely change eral blood culture where the central culture is positive
ventilator circuits. 145 The US Centers for Disease Control ≥2 hours earlier than the peripheral culture or has five
150
recommend changing the ventilator circuit only when it times the growth. Central line associated bactaeremia
is visibly soiled or malfunctioning, and should not be (CLAB) is one of the most important and severe infec-
151
changed more often than every 48 hours unless it is tions that can occur in ICU, and as many as 90% of
soiled or malfunctions. 146 The use of a closed suction bloodstream infections may be attributable to intravascu-
system for endotracheal suction does not decrease the lar catheters. 152 Renal failure may significantly increase
153
incidence of nosocomial infection, 147 but it does afford the risk of infection. Berenholtz et al. demonstrated
a protective barrier to the nurse performing the that implementing quality improvement measures to
procedure. ensure adherence to evidence-based infection control
guidelines results in a significant reduction of catheter-
Selective digestive decontamination has been studied related bloodstream infection. 154
extensively. In theory, the use of antimicrobial agents to
reduce gut flora in intubated intensive care patients The use of antibiotic-impregnated catheters has been
reduces the risk of pneumonia due to microaspiration shown to reduce bacteraemia, 155 and although it is
(see Chapter 19). While most studies have demonstrated common practice in many critical care units to
a reduction in the incidence of VAP, there has been an routinely change intravenous administration sets, with

Essential Nursing Care of the Critically Ill Patient 123

antiseptic-coated catheters they can be used safely for up transport, or within a hospital from one department
to seven days. 156 Currently available evidence supports to another, this being intrahospital transport. 158,159 This
the use of maximal barriers (head cap, face mask, sterile section will focus on intrahospital transport, while inter-
body gown, sterile gloves and full-size body drape) during hospital transport is described in Chapter 22. A large
routine insertion of central venous catheters along with proportion of intrahospital transports occur from the
antiseptic solutions to prepare the skin, and catheter emergency department 160 to the critical care unit. Patients
119
insertion by appropriately trained personnel. Chapter within the ICU may require transport to imaging depart-
3 contains information on central line care bundles and ments for scans or operating theatres for procedures.
checklists. Although chlorhexidine solutions are recom-
mended their effectiveness depends upon the strength of Guidelines for the transport of critically ill patients are
the solution. In Australia decontamination of the inser- available in many countries including Australia and New
158,159,161
tion site is with 0.5% chlorhexidine gluconate in 70% Zealand with the principles applying equally to
162
119
isopropyl alcohol. The use of antimicrobial ointments intrahospital as other transport. Specific guidelines
to prevent local colonisation is recommended for long- may need to be observed for certain groups of patients,
term tunnelled catheters used for haemodialysis. 119 for example those with head injury. A careful assessment
of risk versus benefit should be undertaken before making
Nurses are responsible for the maintenance of central a decision to transport a patient. 161,163 To reduce the risk
venous catheters once inserted, including care of the of adverse events during transport, various diagnostic
insertion site dressing and infusion line management. tests or surgical procedures should be evaluated in terms
The types of dressing commonly used are transparent of their potential to be undertaken in the critical care
semi-permeable and more recently chlorhexidine gluco- unit. 161,164
nate gel dressings. 119,157 Transparent dressings are advan-
tageous because they allow direct observation of the entry ASSESSMENT
site of the catheters. Dressings should be replaced when- As adverse effects may occur in 40–70% of critically ill
119
ever their seal is broken or every seven days. Catheter patients transported within hospitals, 164,165 the primary
hubs are another site of colonisation for microorganisms, focus of assessment should be on patient safety and the
such as Staphylococcus epidermidis and effective hand prevention of adverse events. A transport ‘event’ can be
hygiene combined with non-touch aseptic techniques any event that has an adverse impact and can be patient-,
when accessing the catheter hub should be implemented. staff- or equipment-related. 166 The patient may be
Intravenous administration sets containing blood prod- adversely affected during transport, ranging from anxiety
ucts or lipids or parenteral nutrition infusions are changed or pain to respiratory or cardiovascular compromise. Staff
when the infusion completes or daily, while others may have difficulty with managing the equipment or
can be left for intervals of up to 4 days or changed patient’s needs during transport and equipment related
according to local protocols. Infusions such as propofol problems during transport of critically ill patients are a
or nitroglycerine may have additional manufacturer major consideration. 164-167 Risk–benefit assessment is
guidelines regarding admini stration set changes. 119
helpful to identify patients with a high risk of complica-
After removal of the catheter, and once homeostasis has tions. 163,166 For example, the potential risk of moving a
been established, the site should be covered with an severely head-injured patient with unstable intracranial
occlusive dressing, which should be left in place for 48 pressure may outweigh the potential benefit of a CT scan.
hours to minimise the risk of infection. The catheter Meticulous planning for all aspects of the transport,
should be examined after removal and any damage based on a thorough assessment of the patient’s anti-
reported. It may be hospital or unit policy to send the cipated needs is the key to safe intrahospital trans-
catheter tip for culture and sensitivity. port. 158,163,166 A comprehensive outline of information
addressing key components of intrahospital transport of
critically ill patients should be available to personnel at
every hospital. 158,159,161
Practice tip
Safe transport requires accurate assessment and stabilisa-
Unless contraindicated in a specific patient, a central venous tion of the patient before transport. 158 Key elements 162 are
catheter dressing should be changed whenever there is evi- identified in Box 6.6. All equipment should be checked
dence of fluid accumulation or loss of the dressing’s occlusive for functionality prior to transport and while it is vital to
seal. ensure that sufficient equipment is taken to maintain the
patient, unnecessary equipment complicates the logistics
of managing the transport smoothly. Specifically con-
structed transport beds, or attachments such as equip-
TRANSPORT OF CRITICALLY ILL ment tables, designed to support equipment safely during
PATIENTS: GENERAL PRINCIPLES transfer are useful. 158,163,166 The period of transport should
ideally be as short as possible, although safety should not
The transport of a critically ill patient may occur for be sacrificed for speed. Pre-planning the route of trans-
several reasons, such as from an accident site categorised port and good dialogue between department staff can
as pre-hospital transport, or to move a patient to another help to maximise the efficiency of transport and reduce
facility for treatment which is known as interhospital unnecessary delays. 161,166

124 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



TABLE 6.15 Standard equipment for transport

Circulatory support Pharmacological
Respiratory support equipment equipment Other equipment agents
● Airway management equipment, ● Monitor/defibrillator/external ● Urinary catheter and bag ● Checked and clearly
including intubation set, range of pacer combined unit ● Nasogastric tube and bag labelled drugs:
endotracheal tubes and laryngeal ● Non-mercury ● Nasal decongestant spray standard resuscitation
mask airways, hand ventilation set sphygmomanometer ● Instruments, sutures, dressings, drugs and those
with PEEP valve and emergency ● IV fluids, pressure infusion set, antiseptic lotions, bandages, specific to the patient’s
surgical airway set infusion pumps slings, splints, tape, cutting condition
● Oxygen, masks, nebuliser ● Arterial cannulae and arterial shears, gloves, protective glasses,
● Pulse oximeter and capnography monitoring device torch
● Sufficient oxygen supply ● Syringes and needles, sharps ● Thermal insulation and
● Suction equipment disposal container temperature monitor
● Portable ventilator with disconnect ● Pericardiocentesis equipment ● Equipment for spinal or limb
and high-pressure alarms immobilisation and bandages
● Pleural drainage equipment ● PPE for transport team

influencing safe transport. 158,161,165,166 Staff should be
BOX 6.6 Key elements of safe transfer 163 trained in the various aspects of patient transport, 158,164,166,167
including competent management and troubleshooting
● Experienced staff of all equipment involved. There is some evidence to
● Appropriate equipment suggest that a designated transport team improves quality
● Full assessment and investigation of care. Team members should be aware of their specific
● Extensive monitoring roles and ensure excellent communication throughout
● Careful stabilisation of patient the transport procedure.
● Reassessment
● Continuing care during transfer Equipment used during patient transport must be robust,
163
● Direct handover lightweight and battery-powered, and must adhere to
● Documentation and audit relevant national manufacturing and safety standards.
Equipment-related complications occur in around a third
of transports. 164,166 All equipment must be adequately
restrained during transport, and must be available con-
Practice tip tinuously to the operator. 158 Oxygen requirements should
be calculated in advance (or it should be established that
Not only appropriate staff but appropriate numbers of staff piped oxygen is available at the destination department)
should participate in the patient transport. A nurse cannot to ensure an adequate supply, both for the journey and
monitor the patient, manage events and push the bed as well. for the duration of the investigation/procedure. Standard
equipment for interhospital transport is identified in
Table 6.15; 158 and while some items may be unnecessary
ESSENTIAL NURSING CARE DURING for all intrahospital transport, Table 6.15 provides a
TRANSPORT useful checklist so that all necessary equipment is taken.
Essential care during transport involves three compo- Additional specialist equipment may be required for
certain patients, such as spare tracheostomy tubes in case
nents: the patient, the personnel and the equipment and of accidental extubation.
monitoring. Importantly, the patient and their family
should be given an explanation of why the transport is Before transport, all equipment should be prepared and
necessary, how long the procedure is expected to take and checked, including the function of visible and audible
that the transport process includes the team accompany- alarms. All non-essential therapy should be discontinued
ing the patient to continue monitoring and provide any temporarily during the transport, such as enteral nutri-
required treatment. tion. Where possible, therapies should be simplified,
such as exchanging chest drainage systems for one-way
Nursing responsibilities during transport of the patient
include all aspects of patient monitoring and comfort. valves, or disconnecting completed infusion administra-
All vital signs and equipment parameters should be moni- tion sets from intravenous lines. The patient’s physical
tored and the equipment should be checked regularly to safety should be maintained and care should be taken
ensure correct functioning. Gas reserves and battery time to ensure that bed rails are used and the patient’s limbs
require vigilant attention. Patient safety is paramount and are secure and not likely to be injured by equipment.
close attention to detail is required. Throughout the trans- All vital monitoring and therapy equipment should be
port, patients should be reassured regarding their condi- transferred to portable equipment, and the patient
tion and the progress of the purpose of the transport. should be stabilised before being moved. If the patient
is being transported for magnetic resonance imaging
The level of experience and specialty of personnel involved (MRI), it is important to ensure that all equipment is
in the transport of critically ill patients are factors compatible.

Essential Nursing Care of the Critically Ill Patient 125

prophylaxis and pressure injury prevention, along with a
Practice tip thorough assessment of physical care needs and a subse-
quent plan of management. Consideration of factors
If ceasing nutrition during the patient transport, make sure that such as limb function, which may ultimately reduce the
the patient is not at risk of hypoglycaemia from concurrent deficits in physical function often experienced at least
insulin therapy. transiently by critically ill patients, is another component
of essential nursing care of the critically ill patient. Recov-
ery for patients to normal functioning after a critical
illness is dependent upon a multitude of factors, and is
a dynamic process over time, however, much of the essen-
The need for monitoring relates to both the patient and tial nursing care given to critically ill patients assists in
equipment, and is identified in Table 6.16. 158 Some moni- both reducing deficits associated with their episode of
toring should be continuous, such as cardiac, oxygen illness and reducing the time taken to achieve normal
saturation, capnography if the patient is intubated, and functioning.
arterial, pulmonary artery and intracranial monitoring if
the respective devices are in situ. Intermittent monitoring Good personal hygiene is at the heart of essential nursing
of central venous pressure CVP, non-invasive blood pres- care, and many other aspects of essential care (e.g. eye
sure and respiratory rate should be undertaken as indi- care and oral care) are closely related. Personal hygiene
cated by the patient’s condition. 158,166 is often attended to when patients are repositioned, and
whenever they are moved the nurse has an opportunity
A complete record should be kept of all details of the to assess patients, particularly their dependent pressure
patient’s condition, personnel involved, clinical events, areas.
observations and therapy given during transport. The
transporting team should hand over directly to the receiv- Bowel and urinary catheter care are vital but often
ing team providing continuing care for the patient, 163,167 neglected areas of care. When patients are critically ill, the
or should remain during the intervention/procedure to development of preventable complications such as con-
manage the patient’s care. stipation and urinary tract infection may have significant
consequences for them.
SUMMARY All critically ill patients are at risk of infection, and essen-
tial nursing care requires effective application of surveil-
In the management of critically ill patients there is always
an initial focus on assessing and treating the patient’s lance, prevention and control measures that should be
most life-threatening and immediate problems. Early applied equally to all patients. This principle is embed-
attention should then be given to the implementation of ded in the recommended use of standard precautions.
preventative therapies such as venous thromboembolism Critically ill patients are often transferred to other depart-
ments for further investigation or specific interventions.
All transfers pose a potential risk to patients, particularly
if they are unstable. Essential nursing care of patients
during transfer is based on thorough assessment and
TABLE 6.16 Monitoring during transport preparation in an attempt to anticipate their every need
so that adverse events do not occur.
Clinical patient
monitoring Equipment monitoring This chapter has provided a comprehensive overview of
the general but essential nursing care of critically ill
● Circulation ● Pulse oximeter and capnography
● Respiration ● Breathing system alarms patients. It offers a guideline for nurses, which is relevant
● Oxygenation ● Electrocardiograph for most patients, most of the time. As with all other
● Neurological ● Physiological pressures aspects of nursing practice, nursing care and intervention
● Pain score ● Other clinically indicated equipment should be based on a thorough assessment of each indi-
● Patient comfort (e.g. blood gas analysis)
vidual patient.



Case study

Day 1 On examination Kevin was found to have:
Initial presentation ● difficulty breathing and respiratory rate of nearly 60
Kevin is a 45-year-old male who presented to his local country ● sore throat
hospital with increasing shortness of breath and a 4 day history of ● fever with body temperature of 38.1°C
flu-like symptoms, of fatigue, muscular discomfort, cough and ● decreased air entry and vocal resonance right chest
‘chills’. Kevin is obese and has a past medical history of chronic back ● heart rate @ 120
pain. Kevin lives with his wife and children and works for a local ● SpO 2 71–75% on air with central cyanosis
real estate company. ● blood pressure 96/34

126 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E



Case study, Continued
Initial treatment included: 15L oxygen via non-rebreather system, Day 2
fluid resuscitation of 1.5L with the blood pressure improving to Kevin remained on Pressure control ventilation: FiO 2 0.5–1.0, PEEP
111/42, and broad specrum antibiotics. @ 15, Inspiratory Pressure @ 16 with Nitric Oxide 5–10ppm. Hae-
An urgent portable chest X-ray showed right middle and lower modynamics were supported with noradrenaline, adrenalin and
lobe consolidation and air bronchograms. bicarbonate infusions. Kevin was sedated and administered bron-
chodilators. Antibiotic treatment continued with blood cultures
While there was improvement to SpO 2 readings with the supple- positive for streptococci. Renal function was supported with Hae-
mental oxygen therapy, Kevin’s work of breathing remained high mofiltration. Re-positioning Kevin was limited to small lateral
and following consultation with the intensive care team, arrange- movement because of his continued haemodynamic and respira-
ments were made to transfer Kevin via helicopter to the intensive tory instability. Passive movements of all limbs were instigated
care unit in the city. with physiotherapists assisting with limb and joint movements.
On arrival in ICU Kevin’s problems were severe community acquired pneumonia,
Because of the high suspicion of influenza and the serious respira- shock, acute renal failure and coagulopathy.
tory failure necessitating respiratory support and potential for intu-
bation or bronchoscopy, Kevin was allocated to a single room and Days 3–6
‘contact and droplet’ transmission-based precautions were imple- Volume control ventilation with tidal volumes of 6 mL/L/kg along
mented immediately. with nitric oxide therapy were used to support respiratory func-
tion. PiCCO monitoring was implemented to assist management of
During transport from the country to the ICU, the retrieval team haemodynamic status and continuous veno-venous haemodiafil-
had stabilised Kevin on supplemental oxygen therapy but just tration (CVVHDF) was used for renal support. Strep pyogenes and
prior to arrival in the ICU he was increasingly disorientated and Influenza A H1N1 were confirmed and antibiotic therapy contin-
dyspnoeic and BiPAP therapy was commenced with FiO 2 1.0. The ued. Enteral nutrition was commenced and established over a 4
retrieval team has inserted a central venous catheter and com- day period. A faecal containment device was used to manage
menced a low dose adrenaline infusion to support his blood pres- incontinence and prevent any sacral excoriation.
sure as they did not want to load him with fluids. During transport
Kevin was able to tolerate being semi-recumbent but unable to be Days 7–13
positioned sitting upright while on the barouche due to his large Inotropes were gradually weaned and respiratory function
abdomen causing discomfort to his breathing. improved and nitric oxide ceased. During this time Kevin was
progressively re-positioning more often and with increasing
Kevin was unable to be stabilised on BiPAP and was intubated and lateral turns to aid both his respiratory function and also provide
ventilated using FiO 2 1.0 with PEEP @ 8 on pressure control ventila- pressure relief. Sedation was reduced over this time and ceased
tion (PCV) mode. Tracheal aspirate was obtained and sent for and Kevin was changed to pressure support ventilation (PSV).
microbiological examination including a rapid review for influenza. Kevin responded with his eyes opening to stimuli but he had hypo-
A urinary catheter with temperature monitoring sensor was tonic and areflexic upper and lower limbs. A short-term clonidine
inserted. Kevin was oliguric and his urinary temperature was 39°C. infusion was required for control of a period of severe
Kevin’s haemodynamic instability and de-saturation due to lung hypertension.
compression prevented him from being positioned laterally but
head-of-bed elevation was maintained at greater than 20 degrees. Days 14–20
From initial contact with the local hospital knowledge of Kevin’s Nerve conduction studies confirmed that Kevin had a critical illness
weight had prompted the ICU team to ensure that the bed Kevin polyneuropathy. A progressively increasing respiratory rate and
used had a weight-suitable pressure relief mattress already in decreasing PaO 2 due to low tidal volumes prompted a short return
place. Venous thromboembolism prophylaxis was commenced to pressure-controlled ventilation to re-inflate the lower lobes. A
with a combination of heparin and sequential compression device. tracheostomy was performed to provide long term airway support.
Thigh leggings were chosen along with the sequential compres- Kevin improved again over the next 24 hours and was weaned
sion device in preference to compression stockings because of again to 30% oxygen on pressure support ventilation.
Kevin’s size and potential peripheral oedema.
Days 21–25
After 12 hours following intubation, nitric oxide was added to the Kevin’s limb strength improved with power rated at 4/5 globally.
ventilation system to improve arterial blood gases (ABGs) along Kevin was now able to be supported to sit on the side of the bed
with intermittent muscle relaxants which were also required to twice each day. T-piece oxygenation was now well tolerated during
optimise ventilatory support. Additional attention to Kevin’s eye the day with pressure support ventilation at night. A renal perfu-
care was given with the use of muscle relaxants and the subse- sion scan showed poor perfusion with very delayed function and
quent loss of blink reflex. Hypotension was treated with a further no radioactive excretion. A permacath was inserted to aid with
2 litres of intravenous fluids plus 2 units of red blood cells for a low potential long-term dialysis.
haemoglobin. Antibiotic therapy continued.
Days 26–34
Kevin’s problems included community acquired pneumonia, sepsis Respiratory support was continued with a variation between pres-
and acute renal failure. sure support ventilation and T-piece oxygenation. Intermittent

Essential Nursing Care of the Critically Ill Patient 127



Case study, Continued
dialysis continued to be required up until day 34 when urine Summary
output was consistently effective. Kevin was able to sit out of bed Kevin had a very complicated and serious illness requiring man-
daily with the assistance of initially a lifting machine and then a agement of many critical conditions. Essential nursing care, com-
standing device. munication and psychological support were vital components of
Day 38 his care while in ICU. In addition his haemodynamic and respiratory
Kevin was able to have his tracheostomy decannulated. instability along with his initial size and then the development of
critical illness polyneuropathy limited the ICU team’s options for
Day 40 early mobility and potentially impacted on Kevin’s need for signifi-
Kevin was transferred from ICU to the respiratory unit and then cant rehabilitation before he was able to return home to indepen-
discharged from hospital to a rehabilitation unit on day 53. dent living.










Research vignette

Munroe CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlor- Conclusions
hexidine, toothbrushing, and preventing ventilator-associated Chlorhexidine, but not toothbrushing, reduced early ventilator-
pneumonia in critically ill adults. American Journal of Critical Care associated pneumonia in patients without pneumonia at
2009; 18(5): 428-38. baseline.
Abstract Critique
Background The factorial RCT is a powerful design to test hypotheses of cause
Ventilator-associated pneumonia is associated with increased mor- and effect as was tested in this study. It is interesting to note that
bidity and mortality. a total of 10,910 patients were screened for eligibility, only 13%
(n = 1416) met the eligibility criteria and only 5% (n = 547) were
Objective consented and subsequently enrolled in the study. Consent was
To examine the effects of mechanical (toothbrushing), pharmaco- unable to be obtained for 61% (n = 869) of those eligible. This
logical (topical oral chlorhexidine), and combination (toothbrush- points to a real difficulty in conducting trials in the ICU setting;
ing plus chlorhexidine) oral care on the development of large numbers of patients may have to be screened with many of
ventilator-associated pneumonia in critically ill patients receiving those eligible not subsequently participating due to consent
mechanical ventilation.
issues. A clear description of the interventions were described. For
Methods example, the toothbrushing protocol was described in detail and
Critically ill adults in 3 intensive care units were enrolled within 24 involved dividing the mouth into quadrants and brushing each
hours of intubation in a randomised controlled clinical trial tooth for five strokes using Biotene toothpaste, which was based
with a 2 x 2 factorial design. Patients with a clinical diagnosis on the American Dental Association’s recommendations. The
of pneumonia at the time of intubation and edentulous details about the interventions allow others to replicate them in
patients were excluded. Patients (n = 547) were randomly future research, however, the researchers did not mention collect-
assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral ing data on intervention fidelity, or the extent to which the tooth-
swab twice daily, toothbrushing thrice daily, both toothbrushing brushing and chlorhexidine swabbing were actually performed as
and chlorhexidine, or control (usual care). Ventilator-associated was planned. Further, it is not clear what ‘usual care’ was in the
pneumonia was determined by using the Clinical Pulmonary Infec- study sites.
tion Score (CPIS).
Two issues are important to consider when examining the findings.
Results First, complete data was only available for 192 of the 547 patients
The four groups did not differ significantly in clinical characteristics. randomised, which represents a 35% retention rate (i.e. 65 % loss
At day 3 analysis, 249 patients remained in the study. Among to follow up). Second, 54% (105 of 192) patients recruited to the
patients without pneumonia at baseline, pneumonia developed in study did not meet the eligibility requirement because they already
24% (CPIS ≥6) by day 3 in those treated with chlorhexidine. When had pneumonia, yet they were randomised. Both issues may com-
data on all patients were analyzed together, mixed models analysis promise the randomisation process. Specifically, randomisation is
indicated no effect of either chlorhexidine (P = 0.29) or toothbrush- a method to try to ensure the groups are similar in all known and
ing (P = 0.95). However, chlorhexidine significantly reduced the unknown characteristics, which is important in that this will control
incidence of pneumonia on day 3 (CPIS ≥ 6) among patients who for the effect of potential confounders. While the researchers
had CPIS <6 at baseline (P = 0.006). Toothbrushing had no effect present the subgroup analysis of those without pneumonia, this
on CPIS and did not enhance the effect of chlorhexidine. analysis may not represent ‘random’ allocation to the various