Ethics, End-of-Life Care and ICU Administration
This domain tests reasoning rather than recall: capacity, consent, ceilings of treatment, family communication and the quality metrics an ICU director would report. Answers that ignore the patient's values lose marks even when the medicine is right.
Consent, capacity and surrogates
Adults are presumed to have capacity. Assess four elements: understanding the information, appreciating the consequences, reasoning with it, and communicating a choice. If capacity is absent, act in the patient's best interests, using a previously expressed wish first and a surrogate's substitute judgement second. In emergencies, treat under necessity. Document who decided, what was explained, and why. Know your institution's and national regulator's rules on surrogate hierarchy and documentation, because they differ.
Withholding and withdrawing
There is no ethical difference between not starting a treatment and stopping it. Hold a structured family meeting: establish what the family understands, agree the goals of care, and only then discuss specific interventions. The SPIKES framework structures bad news. A time-limited trial is a legitimate tool - define the intervention, the duration and the criteria for success, then review. Dying patients should have symptoms treated: opioids for pain and dyspnoea, midazolam for agitation, with the doctrine of double effect applied to symptom relief and never to hastening death. Terminal sedation is not euthanasia.
ICU administration and quality
Measure what matters: standardised mortality ratio against APACHE or SAPS, ventilator-associated pneumonia and catheter-related bloodstream infection rates per 1000 device-days, hand hygiene compliance, unplanned extubation, readmission, length of stay and family satisfaction. Run daily multidisciplinary rounds with a checklist and use the ABCDEF bundle. Report incidents without blame and disclose errors to patients. Triage during surge must be transparent, consistent and reviewed. Organ donation after brain death should be raised separately from end-of-life decisions, by trained staff.
Worked example
An 84-year-old with a large intracerebral haemorrhage and GCS 4 is admitted, and the family demands everything. Capacity is absent. Hold a meeting away from the bedside, ask what the patient valued, explain that ventilation will not restore independence, and offer a time-limited trial of 48-72 hours with explicit review criteria. Document the discussion and the agreed ceiling of treatment.
Traps
Treating a family's request as consent to futile treatment. Writing DNR without specifying which interventions are withheld. Raising organ donation in the same breath as withdrawing care. Discussing resuscitation status only at the moment of arrest.