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Research Ethics In The Intensive Care Unit

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Research Ethics In The Intensive Care Unit

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Discuss about the Report of Research Ethics In The Intensive Care Unit.

An Intensive Care unit (ICU) is a specialized department of any hospital, where patients with severe, critical and complicated illnesses are constantly monitored, until their body condition is stabilized. ICU’s are also segregated on basis of their specificity, such as the Neonatal ICU, Pediatric ICU, Post surgical ICU, Trauma ICU, Burns ICU, etc.   The ICU in Alfred Hospital, Australia, is an advanced unit with extensive facilities for patients and their caregivers. The staff-patient ratio in the ICU’s is always higher when compared to the postoperative or recovery wards, as the patients cannot be afforded to be left unattended; even a minute of improper monitoring would lead to mis-management and unwanted complications.
Working in the intensive care unit of a hospital can be physically and mentally tiring, as one must always be on his toes, constantly monitoring the patients. (Doric, 2008) There is another dimension to the workload, and that is the ethical aspects that are needed to be taken to be considered, but are often relegated as the least important priorities. Even though ethics are personal tenets, there needs to be an ethical harmony among the staff, so that patient management goes on unhindered. Performing a research in the confines of an ICU is not very easy, but is highly essential to understand the effectiveness of medical care in the critical stages of illness. However, there are a lot of ethical dilemmas which the staffs of the ICU face, which affects their performance badly and tends to question their own motives.
This paper analyses the ethical considerations on performing a survey among staff and patient families in the Intensive Care Unit of Alfred Hospital, (The Alfred Hospital, 2014) its relevance to the corresponding issues addressed in the ethics application form, and effective management strategies in obtaining an ethical clearance for those issues.
Ethical Implications of ICU Research
Upon conducting a study involving the ICU, its staff, and its patients, it is most important to know that the conditions out there are highly dynamic, and things can go from stable to deteriorating in a matter of minutes. (Luce & White, 2009) As a result, the staffs are on a high alert, and high on stress. There are also strict unwritten rules on privacy and confidentiality, so the staff might not divulge much to the interviewer. Three major ethical implications are discussed, with their corresponding link in the ethics application mandated by the National Ethics Application Form (NEAF) of the Australian Government. (Australian Government, NHMRC, 2015) The effective strategies which could be employed in order to obtain ethical approval are also discussed.
A Conflict of Opinions and Decisions
There is always the need to make decisions that can be very difficult to the decider; whether it is admission into the ICU, change in treatment protocols, taking the patent off life support, etc, without the patient having a say on it. Though medical knowledge and logic prevails over emotions, the decision maker is challenged ethically. An honest opinion by the nurse in charge might not go well with the patient, and a professional expertise of the anesthesiologist might be just unacceptable by the surgeon. Sometimes, a conflict of opinions might prove to be a very costly mistake. (Breen, 2001) However, all these issues would be kept highly confidential.
This issue co-relates to the section of taking ownership of the research information, in the ethics application. The ownership of the information shall strictly with the researcher, in order to safeguard the privacy of the interviewee.
The strategy that shall be employed, in order to obtain ethical clearance for this issue shall be mandating the maintenance of anonymity of the persons interviewed, thus protecting their identity. It shall be reiterated that the decisions made by the staff are the best that they could do in certain circumstances even though it might not have been favorable to the patient. (Nelson, 1997)
Ethical Dilemma
A staff of the ICU has to deal with either prolonging the vitals of a person by putting him on life support, or taking the person off life support and let Nature do its course. In both cases, the action is dependent on the decisions of the physicians, nurse, and the caregivers of the patient, but the ethical responsibility lies with the staff in charge of the patient. Sometimes, a critically ill patient might have to be discharged from the ICU, in order to accommodate an even more critically ill patient. This sometimes is futile, as the patient’s health status tends to deteriorate, and sometimes this premature discharge could be fatal. But, that is the way the process is, owing to limited beds in the ICU. This puts the staff under severe ethical pressure, which they have to deal with very often. (Chow, 2014)
This issue co-relates to the question “Is there a risk that the dissemination of results could cause harm of any kind to individual participants – whether their physical, psychological, spiritual, emotional, social or financial well-being, or to their employability or professional relationships – or to their communities?” from the ethics application.
The strategy that shall be employed, in order to obtain ethical clearance for this issue shall be avoiding probing into details which cause unwanted sensitive reactions and repercussions from the interviewee. For example, a patient with no caregivers, it is the responsibility of the staff to decide on his stay in the ICU, and to introduce or remove life support if needed. However, this action might have legal implications, which might be dangerous for the staff and the hospital as well. Thus, no question that is sensitive to the point of discomfort shall be asked, and the integrity of the participant would be maintained. (Sprung & Cohen, 2003)
Encountering Psychological Stresses
Any hospital staff is exposed to death so much, that they might appear to be immune to it. (Azoulay, 2005) But on the contrary, constant exposure to patent’s dying causes a psychological burden, sometimes leading to guilt if they had had a chance a chance to handle the patient. Usually, this leads to an ethical dilemma when presented with a patient having a similar condition in the future; whether treating him the same way would risk his life, and whether treating him differently would cause newer complications. (Oerlemans et al., 2015)
This issue is related to the section of the ethics application, which deals with obtaining willing consent of the participant. Often, the medical staff tends not to refuse consent to a researcher, as they feel obligated to the medical fraternity. However, this leads to several issues affecting the staff.
The strategy that shall be employed, in order to obtain ethical clearance for this issue shall be asking questions to the participants only when they are willing to respond, and not make it an obligation to answer. For instance if a physician had erred on a drug dosage, and the patient had succumbed to it, he must not be made to talk about it unless he volunteers to. (Osmon, 2004) The interview shall be direct, and shall be stopped on the event of the staff feeling uncomfortable on answering them.
Taking a closer look at all the three issues, it is evident that they all point to one trait – decision making. The staff of the ICU, or any hospital staff has to be rational and quick in their decision making process, which would save them from many complications later. However, ethical issues are bound to crop up even with good decision making, as the patient concerned is unable to provide any input except his physical status, which is reduced to just numbers. Hence, confronting the staff on their stance in the ICU must be done only if they consent to it.
Ethics is the most important component in life, with ethical decision making being an integral part of life. In the ICU, where critical care is mandated, a lot of ethical dilemmas are bound to occur; this affecting the staff concerned. Interestingly, these issues carry a low ethical risk, when compared to certain other cases dealing with criminal and legal issues. It must be understood that the staff in the ICU work to their full capacity, going beyond their means to save the patient’s life and stabilize his vitals. Sometimes, it is beyond their control that mistakes happen, yet they feel morally bound to take responsibility for the issues. In short, healthcare professional become second victims of their own practice.
As a researcher, it is important that the research be carried out considering all ethical implications and considerations. Questioning the staff on the grounds of an interview must be done with great care, as there would be many sensitive issues, and answering them would cause several repercussions, as several issues are bound by confidentiality. (Patten, 2007) On a positive note, it is research that makes the world aware of the ethical issues faced by the staff. Thus, it must be used wisely and with discretion, if a productive gain is expected out of the research. Maintaining high levels of ethics in performing research would ensure quality research and would provide to the outside world a good understanding of the ICU and its immense ethical content.
Australian Government, NHMRC, 2015. National Ethics Application Form (NEAF). [Online] Available at: https://www.nhmrc.gov.au/health-ethics/national-ethics-application-form-neaf [Accessed 03 August 2016].
Azoulay, E..P.F.., 2005. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. American journal of respiratory and critical care medicine, 171(9), pp.987-94.
Breen, C.M., 2001. Conflict associated with decisions to limit life‐sustaining treatment in intensive care units. Journal of general internal medicine, 16(5), pp.283-89.
Chow, K., 2014. Ethical Dilemmas in the Intensive Care Unit. Journal of Hospice and Palliative Nursing , 16(5), pp.256-60.
Doric, A.G..D.E.L.T.K.N., 2008. The impact of an ICU liaison nurse service on patient outcomes. Critical Care and Resuscitation, 10(4), p.294.
Luce, J.M. & White, D.B., 2009. A History of Ethics and Law in the Intensive Care Unit. Critical Care Clinicians, 25(1).
Nelson, R.M., 1997. ETHICS IN THE INTENSIVE CARE UNIT – Creating an Ethical Environment. Critical Care Clinics, 13(3), pp.691–701.
Oerlemans, A.J., Sluisveld, N.v. & Leeuwen, E.S.v., 2015. Ethical problems in intensive care unit admission and discharge decisions: a qualitative study among physicians and nurses in the Netherlands. BMC Medical Ethics, 16(9).
Osmon, S..H.C.B..D.W., 2004. Reporting of medical errors: an intensive care unit experience. Critical care medicine, 32(3), pp.727-33.
Patten, M.L..&.B.R.R., 2007. Understanding research methods: An overview of the essentials. Pyrczak Publishers.
Sprung, C.L. & Cohen, S.L., 2003. End-of-life practices in European intensive care units: the Ethicus Study. Journal of American Medical association, 290(6), pp.790-97.
The Alfred Hospital, 2014. The Alfred Intensive Care Unit. [Online] Available at: https://www.alfredicu.org.au/ [Accessed 3 August 2016].

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