17.2 Ethical/Legal Issues, End-of-Life & Goals of Care

The Six Ethical Principles

CCRN ethics items are answered by mapping a scenario to a core bioethical principle. Memorize these six and one ICU application each.

When a competent patient refuses treatment (a Jehovah's Witness declining blood, a terminally ill patient declining aggressive care), the governing principle is autonomy, and the nurse advocates for the patient's expressed wishes. When family asks the team to withhold a poor prognosis from a competent patient who wants to know, veracity and autonomy require honest, compassionate disclosure to the patient.

Informed Consent and Capacity

Informed consent requires that the patient receive the nature of the procedure and its risks, benefits, and alternatives, and consent voluntarily. The provider performing the procedure is legally responsible for that disclosure. The nurse's role is to witness the signature, confirm the patient understands and is consenting freely, and notify the provider if the patient does not understand or seems hesitant—the nurse does not re-consent the patient. Capacity is a clinical determination that the patient can understand information, appreciate consequences, reason, and communicate a choice; it can fluctuate. Competence is a legal determination made by a court. A patient may lack capacity temporarily (sedation, delirium) yet still be legally competent.

Ethical Dilemmas and Moral Distress

Moral distress occurs when a nurse knows the ethically correct action but is constrained from taking it—for example, repeatedly delivering aggressive care believed only to prolong suffering. Unaddressed, it accumulates as moral residue and drives burnout. A constructive, professional response is to acknowledge it and use resources: an ethics consultation, interdisciplinary discussion, structured debriefing, and peer/organizational support. AACN's 4 A's framework—Ask, Affirm, Assess, Act—gives a stepwise way to address distress rather than suppress it.

Advance Directives and Surrogate Decision-Making

Advance directives let patients direct care when they can no longer speak for themselves.

When a patient lacks capacity and has no directive, the legally recognized surrogate decides using substituted judgment—what the patient would have wanted based on their known values—and falls back to the best-interest standard only when the patient's wishes are unknown. A DNR order directs only that CPR not be performed on arrest; it does not mean withdrawing other treatments or comfort measures, which continue per the plan of care. A DNI order withholds intubation while other care may proceed.

End-of-Life Care: Palliative, Hospice, and Withdrawal

Palliative care is symptom- and quality-of-life-focused care that can be delivered alongside curative treatment at any disease stage. Hospice is a subset of palliative care for patients with a prognosis generally of six months or less who have chosen comfort over cure. When care transitions to comfort-focused (palliative) goals, the CCRN nurse's priority shifts to aggressive management of pain, dyspnea, and anxiety, psychosocial/spiritual support, and presence with the patient and family; nonessential monitoring and interventions are discontinued. During withdrawal of life-sustaining therapy consistent with the patient's wishes, the nurse provides expert comfort care, supports the family, and ensures a dignified process. The principle of double effect permits giving opioids/sedatives to relieve suffering even if a foreseen (but unintended) side effect is hastened death, provided the intent is symptom relief.

Confidentiality, HIPAA, and Medical Futility

Confidentiality is an expression of fidelity. Under HIPAA, the nurse follows the minimum-necessary rule: access only the records required for the patient's care and share protected health information only with those directly involved in care or as legally permitted. Discussing patients in elevators, looking up a colleague's or celebrity's chart out of curiosity, and posting any identifiable detail on social media are violations. Medical futility—when an intervention cannot achieve a meaningful benefit—often triggers conflict between families requesting "everything" and a team that judges further aggressive care non-beneficial. The nurse's role is to facilitate communication, clarify goals of care, and use the ethics consultation and interdisciplinary process rather than acting unilaterally; autonomy does not obligate clinicians to provide non-beneficial treatment.

Brain Death, Organ Donation, and Family Support

Brain death is a clinical diagnosis: coma of known irreversible cause, absent brainstem reflexes, and a positive apnea test, after excluding confounders (hypothermia, drugs, metabolic derangement); ancillary tests (cerebral blood-flow or EEG studies) are used only when the clinical exam or apnea test cannot be safely completed. A brain-dead patient is legally dead even while organs are perfused. Best practice "decouples" the death notification from any organ-donation request: trained organ procurement organization (OPO) staff—not the bedside nurse—approach the family, which improves the family experience and consent rates. Donation after brain death (DBD) differs from donation after circulatory death (DCD), in which death is declared by cardiopulmonary criteria after a planned withdrawal. Throughout end-of-life care the nurse supports the family, offers the option of family presence during resuscitation with an assigned support person, and honors the patient's and family's cultural and spiritual practices.