Ethics, Palliative Care, Patient Safety, and ICU Administration
Decision-making
Assess capacity for each specific decision. Patients with capacity may refuse any treatment, including life-sustaining therapy. Without capacity, surrogates use substituted judgment, prioritizing the patient's previously expressed values, and best interests only when values are unknown. Advance directives and documented goals of care should be sought early. For unrepresented patients, use a time-limited trial in the patient's best interest with ethics consultation.
Withdrawal, DNR, and futility
Do not equate a DNR order with withdrawal of other therapies; DNR applies to resuscitation, not to antibiotics, dialysis, or pressors. Withdrawal of mechanical ventilation and vasopressors is ethically and legally accepted when consistent with the patient's values or when burdens outweigh benefits. Provide analgesia and sedation for comfort, including opioid for dyspnea, accepting the doctrine of double effect.
Communication and conflict
Structured family meetings, consistent messaging, and clear documentation reduce conflict. Conflicts about "futility" are better framed as proportionality of benefit. Ethics committees help, but unilateral clinician refusal of requested treatment is legally constrained in many jurisdictions.
Safety and administration
Handoffs, checklists, central line and ventilator bundles, delirium prevention, restraint minimization, and medication reconciliation are the highest-yield safety interventions. Transparent disclosure of medical errors is an ethical obligation.
Traps
- Assuming a DNR order means no escalation of any therapy.
- Allowing family to demand non-beneficial treatment without a process.
- Failing to document capacity assessment and goals-of-care discussions.
Rule of thumb
Before any major decision, answer three questions: what does the patient want, what can medicine offer, and what does the surrogate believe the patient would choose?