Admission Procedure for the Critically Ill Patient

In unit one of the General Nursing module you learntthe general procedure for admitting a patient. Whilst dealing with a critically ill patient in your hospital, the admission procedure depends on previously laid down procedures as well as on the physician/clinician's assessment of the resources available for caring for the patient. This implies that only those who are critically ill and whose critical pathway warrants admission to an intensive care unit should be given access. In critical care nursing, life-saving techniques should be administered first. Other admission protocols follow. The first step in the admission procedure is determined by the individual patient's condition. That is why it is very important for you to be able to evaluate the patient's condition immediately to identify those who deserve admission.

Once a decision for admission is established, the patient's data is collected and entered into the admission records. Relatives, or those who escorted the patient to the hospital, should give the patient's personal details, such as name, address, residence and contact telephone number. You should remember that the procedure followed in the admission of patients might differ from hospital to hospital, based on the management policy of each hospital. However, the general procedure is to deal with the biological problem of the patient first, so as to save and sustain life, before considering any other protocols suchas finances.The relatives' involvement during admission is crucial and they should be fully informed of the proceedings and what is expected of them,what role are they expected to play,whether they are expected to provide financialsupport, when they can visit, how they are expected to conduct themselves during the visit, etc.Though the patient may be unconscious they should always be referred to by their name during the admission procedure and during the care. This builds both the patient's and relatives' confidence in the critical care team and promotes two-way communication (nurse-patient relationship). As you well know, better understanding of the prognosis by physicians, patients and their families reduces the amount of futile care. Resources are better spent where results are likely to be achieved!On the other hand, all parties involved must agree on how best to reduce the cost of hospital care and families must be fully informed of financial implications when their loved ones are admitted into intensive care units.

Criteria for Admission Intensive care is a service for patients with potentially recoverable diseases who can benefit from a more detailed observation and treatment than is generally available in a general ward. The decision to allow an admission to ICU lies on the doctor empowered with the right of admission by the specific institution. However the patient has tomeet any of the following categories: Admission for continuous monitoring and observations. A patient who looks stable may have a likelihood of recognisable life threatening complication, for example post myocardial infarction, after pace maker insertion, post cardiac catheterisation, etc. Patients who need extensive and specialised nursing carefor example,patients for strict fluid input administration like DKA and burns. Patients requiring constant physician care where doctors and nurses remain at the bedside to attend to any changes and institute therapy, for example after cardiac (open heart) surgery.In view of these findings, the admission criterion to intensive care units is selective to avoid stretching the limited resources, while at the same time saving the lives of all those at risk.

Ethical/Legal Issues in Critical Care

Since the 1980's, society has established the primacy of informed consent to medical treatment. You are all familiar with the term 'informed consent', especially in the area of surgical operation and family planning. Informed consent basically means the right of a patient or a relative to make a choice based on clear understanding of the risks and benefits of the different alternatives available. In this unit, a broader definition of informed consent which does not only imply the patient's right to chose between alternative treatment, but also their right to refuse to have any treatment at all will be taken. Of course, decisions to refuse treatment are most weighty when the medical interventions being refused are life saving or life prolonging. You will now move on to the legal implications of these delicate issues. It is agreed and well known that sometimes, adult patients may refuse any and all life-sustaining intervention. When a patient takes the choice of refusing treatment, the morally acceptable alternative decision on the part of the clinician is either to transfer care to another clinician, or to follow the patient's wish. That is why a patient who refuses to comply with a physicians advice is requested to sign a declaration to that effect. A good example is the discharge of a patient against medical advice. Now look at the other side of the issue whereby it has been established that additional or continued life-sustaining measures are futile. You will agree that often there are difficulties in precisely delineating futility. Ordinarily, physicians feel responsible for their patients and always try to endorse the right treatment to save lives. When they are faced with a decision to terminate further treatment, they are faced with a big dilemma.

Case One Baby K was born in 1992 with anencephaly and contrary to usual custom, her mother (who refused abortion when a diagnosis of anencephaly had been made in theuterus) insisted that Baby K be kept alive by all means possible. The physicians and hospital took the case to federal court where it was first heard by the US District Court and then the US Court of Appeal. Both courts upheld the mother's right to demand treatment although the diagnosis and prognosis were not in dispute.

Case Two When Catherine Gilgum, a 17 year old woman at the terminal stage of her illness lapsed into a coma, her physicians at Massachusetts General Hospital suggested that a do-not resuscitate order be written.A representative of the hospital ethics committee, called in by Catherine's physician, wrote a note in the chart, supporting unilateral action by the physician. The ethics committee representative did not attempt to mediate the dispute. In fact, he did not speak with the patient's family. He went against the expressed wishes of the patient's family and the patient's previously stated wishes that she wanted everything done. Catherine died after her physician wrote unilateral orders for both do-not resuscitate and discontinuation of mechanical ventilation.In Case One, religious beliefs were major factors in baby K's case, which is why her mother continued demanding treatment even though she was aware that the baby would eventually die. The courts ruled in her favour. In Catherine's case, Case Two, the ethics standards were not followed since the decision was unilateral. The family was not even informed. From these two cases, it can be concluded that it is difficult to prove medical futility, resolve treatment decision conflicts, and draft policies on medical legal issues without bilateral consensus (Johnson et al, 1997). There are many times when patients and families demand futile treatment because clinicians focus on specific treatment rather than on the goals they may or may not achieve. Think about it! How well the goals of the operation were explained to the last patient whom you were involved in pre-operative preparation? Occasionally, people demand futile treatment when they do not understand the facts. Studies that have been carried out indicate that there was a high increase in the number of relatives and patients who consented to termination of cardiac pulmonary resuscitation after being candidly informed of their condition and prognosis. Another problem area is when health workers give contradicting and inconsistent information to the patient and their relatives. This often leads to a continuation in demand for futile treatment. A good example here is when patients are operated on or put under certain treatment for research or experimental bases without being given adequate information. Such patients may have problems understanding the difference between surgical treatment for cure and surgical operation for research purposes. Furthermore, they become confused when they are cared for by multiple consultants, each of whom watch the progress of one part of the problem and gives feedback on their area of care only. This fragmentation of the patient leads to one consultant giving a promising feedback, for example, 'The heart is beating stronger today', but failing to convey the overall picture of the patient's deterioration. What you can conclude from thissection is that: Informed consent implies the right of the patient to demand, select and even refuse treatment. Physicians/clinicians would be ethically failing in their moral duty if they take unilateral decisions in patient care, while failing to inform patients/relatives about the goals of the treatment. The patient and relatives must be candidly and completely informed to remove ignorance while seeking medical care. This will ensure scanty resources are used on positive goals rather than futile goals. Integration is necessary while providing feedback to patients and relatives to avoid confusing them on the patient's prognosis.Socio-cultural and economic factors will continue to influence perceptions and attitudes of people and hence their health care. This view is supported by Engelhardt et al (1986) who suggested the use of the ICU treatment entitlement index.

The ICU treatment entitlement index (ICU E.I.) multiplies: (P) - Potential benefit of treatment (P) (Q) - The quality of life expected (Q) (L) - Remaining length of life (L)And divides them with the cost (C) The formula looks as follows:ICU E. I. = PQL CWhat this formula does is to guide a person when they have to make a choice between providing intensive care to two equally demanding patients. Engelhardt argues that the use of such a formula would be a better way of endorsing implementible policy regarding the use of scarce resources in general and ICU in particular.Now move on to look at liability issues and patients who are denied medical care. Under both the Hypocritical Oath and the Nurses' Pledge, no patient should be denied medical/nursing care. At the same time, news media occasionally highlight cases where patients were either denied treatment or detained in hospital for inability to meet the cost of treatment. Indeed, hospital institutions and individual clinicians have been sued for liability after denying medical care to patients. Insurance companies offering medical cover are also at times accused of refusing to give medical cover to certain categories of people, for example, those suffering from Acquired Immune Deficiency Syndrome (AIDS). In general, courts look at these cases as a contract dispute between parties. The discussion of terminating life-sustaining therapy in hopelessly ill patients is always an emotional one. This is because many believe that doing so makes one an agent of death. Thus, there are those who prefer to withhold support right from the beginning rather than withdrawing this support later. You can see that the two are ethically equivalent since they both lead to unimpeded progression of the disease, thus leading to the same end-result. Therefore, neither can be said to be wholly ethically acceptable.

What do you understand by the term 'informed consent'?Informed consent basically means the right of a patient or a relative to make a choice based on clear understanding of the risks and benefits of the different alternatives available. In this unit, a broader definition of informed consent is taken which does not only imply the patient's right to chose between alternative treatment, but also their right to refuse to have any treatment at all.