Non patient autonomy that governs decision­ making and

Non maleficence is the companion-in-arms of bene­ficence. It reminds the physician that above all, they should do no harm. Beneficence and non maleficence may at times in a critical care setting be in apparent conflict.

The second basic ethical principle governing decision making in critical care medicine is patient autonomy.

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This is the patient’s right to self-determination the right, after being properly informed, to accept or refuse medical treatment offered to him including life-support measures like mechanical ventilation.

It is indeed the proper inter­pretation of the balance between the principle of beneficence and the principle of patient autonomy that governs decision­ making and management in critical care medicine.

This balance is indeed difficult because patients who are seriously ill may be unable to make proper decisions about their own care.

There are many factors which distort, prejudice or interfere with autonomous decisions of patients in critical care medicine. These include fear, anxiety, and depression, and panic, lack of information and abhorrence of invasive modalities of treatment which prompt them to decide (often wrongly) to “die with dignity”.

The working ethical principle is that when confronted with a potentially reversible life-threatening illness, beneficence prevails over patient autonomy.

The third and final ethical principle is justice-to distinguish in patient care the right from the wrong. If, at times this is difficult or impossible to determine in absolute terms, one should determine what is more right or less wrong.

In developing countries where resources are limited, justice dictates that treatment is administered to patients who are more likely to benefit from them.

This often produces an ethical quandary. Physicians should unques­tionably be involved in the ethics of resource distribution, providing equitable medical care to the society in which they live and work.

Wisdom however, dictates that in all situations requiring protracted intensive care, the burden- benefit relationship should be carefully considered, and care be tempered with reason.

Ethical Issues in Terminal Illness:

A terminal illness is one that leads to death in the immediate future, so that the physician concentrates not on cure, but on relief of symptoms and on moral support to the patient and his family.

At times a patient with terminal cancer or terminal advanced organ system failure is unwittingly admitted to a critical care unit. If such an admission does occur, one should explain the futility and the crippling expense likely to be incurred, to the patient and his family.

Nevertheless, an all-important provision in relation to terminal illness in critical care medicine is to constantly review the word “terminal”.

Such a situation should prompt the physician, to refrain from using medical technology and skill that merely prolong suffering or that make death excessively lonely, gruesome, dehumanized, perhaps even obscene, and ruinous to the patient and his family.

Withholding life support and withdrawal of life support system:

It is comparatively easy to withhold life support in a patient who will invariably die in a short span of a few hours, or even a few days. It may be difficult to withheld support when the time span of a terminal illness is more prolonged.

The discerning physician learns to recognise the limits of care, knows when to draw the line, and recognise the futility, and often the cruelty of aggressive management in patients who are well past the point of no return.

At last the authorities that we have passed an act in Parliament recognising brain death and thereby permitting the withdrawal of life support in patients who are brain dead.

Recognition of brain death and the sanction to remove life support in such patients ends an agonizing era of utter helplessness and mental agony and torture for both relatives and staff in critical care units.