Ethical and Legal Dilemmas in Accessing Critical Care Services

  • N. M. Danjoux
  • L. Hawryluck


There is a growing need for critical care services, with increasing demands due to demographic trends, technological advances, growing costs of standard care, unexpected surges in demand, and public expectations. With the practice of critical care medicine evolving so rapidly due to the ability to sustain lives indefinitely, patients are living longer in the intensive care unit (ICU). As a result, patients and caregivers are faced with difficult decisions, often based on differing opinions on the appropriate use of newly emerging, potentially life-sustaining, yet expensive interventions. When conflicting views are held, their resolution can place undue strain on families and caregivers. To help deal with these situations, some institutions have developed guidelines and policies to reflect best standards to help guide difficult decisions about limits to treatment. However, there is no consensus on the use of such guidelines and their application in practice.


Intensive Care Unit Advance Care Planning Multicultural Society Medical Futility Critical Care Service 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Pochard F, Abroug F (2005) End-of-life decisions in ICU and cultural specificities. Intensive Care Med 314:506–507CrossRefGoogle Scholar
  2. 2.
    Faber-Langendoen K, Lanken PN (2000) Dying patients in the intensive care unit: forgoing treatment, maintaining care. Ann Intern Med 133:886–893PubMedGoogle Scholar
  3. 3.
    Cook D, Rocker G, Marshall J, Griffith L, McDonald E, Guyatt G (2006) Levels of care in the intensive care unit: a research program. Am J Crit Care 15:269–279PubMedGoogle Scholar
  4. 4.
    Rodriguez KL, Young AJ (2006) Elderly veterans’ beliefs concerning life-sustaining treatment and the control of their end-of-life health and health care. J Aging Health 18:686–706PubMedCrossRefGoogle Scholar
  5. 5.
    Hawryluck L (2006) “Informing Advance Care Planning: What are we really talking about?” A multimedia development project presented for the Change Foundation. Ian Anderson Continuing Education Program in End-of-Life Care.Google Scholar
  6. 6.
    Singer PA, Martin DK, Kelner M (1999) Quality end-of-life care: patients’ perspectives. JAMA 280:163–168CrossRefGoogle Scholar
  7. 7.
    Heyland DK, Dodek P, Rocker G, et al (2006) What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 17:627–633Google Scholar
  8. 8.
    Teres D (1993) Trends from the United States with end of life decisions in the intensive care unit. Intensive Care Med 19:316–322PubMedCrossRefGoogle Scholar
  9. 9.
    Pochard F, Lanore JJ, Bellivier F, et al (1995) Subjective psychological status of severely ill patients discharged from mechanical ventilation. Clin Intensive Care 6:57–61PubMedCrossRefGoogle Scholar
  10. 10.
    Shalowitz DI, Garrett-Mayer E, Wendler D (2006) The accuracy of surrogate decision makers: a systematic review. Arch Intern Med 166:493–497.PubMedCrossRefGoogle Scholar
  11. 11.
    Schneiderman LJ, Jecker NS, Jonsen AR (1996) Medical futility: response to critiques. Ann Intern Med 125:669–674PubMedGoogle Scholar
  12. 12.
    Vincent JL (1999) Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 27:1626–1633PubMedCrossRefGoogle Scholar
  13. 13.
    Keenan SP, Busche KD, Chen LM, Esmail R, Inman KJ, Sibbald WJ (1998) Withdrawal and withholding of life support in the intensive care unit: a comparison of teaching and community hospitals. The Southwestern Ontario Critical Care Research Network. Crit Care Med 26:245–251PubMedCrossRefGoogle Scholar
  14. 14.
    Prendergast TJ, Luce JM (1997) Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 155:15–20PubMedGoogle Scholar
  15. 15.
    Ferrand E, Robert R, Ingrand P, Lemaire F (2001) Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. French LATAREA Group. Lancet 357:9–14PubMedCrossRefGoogle Scholar
  16. 16.
    Eidelman LA, Jakobson DJ, Pizov R, Geber D, Leibovitz L, Sprung CL (1998) Foregoing life-sustaining treatment in an Israeli ICU. Intensive Care Med 24:162–166PubMedCrossRefGoogle Scholar
  17. 17.
    Luce JM (1990) Ethical principles in critical care. JAMA 263:696–700PubMedCrossRefGoogle Scholar
  18. 18.
    Palda VA, Bowman KW, McLean RF, Chapman MG (2005) “Futile” care: do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses. J Crit Care 20:207–213PubMedCrossRefGoogle Scholar
  19. 19.
    Giannini A, Consonni D (2006) Physicians’ perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting. Br J Anaesth 96:57–62PubMedCrossRefGoogle Scholar
  20. 20.
    Luce JM, Alpers A (2000) Legal aspects of withholding and withdrawing life support from critically ill patients in the United States and providing palliative care to them. Am J Respir Crit Care Med 162:2029–2032PubMedGoogle Scholar
  21. 21.
    Frick S, Uehlinger DE, Zuercher Zenklusen RM (2003) Medical futility: predicting outcome of intensive care unit patients by nurses and doctors—a prospective comparative study. Crit Care Med 312:456–461CrossRefGoogle Scholar
  22. 22.
    Giannini A, Pessina A, Tacchi EM (2003) End-of-life decisions in intensive care units: attitudes of physicians in an Italian urban setting. Intensive Care Med 29:1902–1910PubMedCrossRefGoogle Scholar
  23. 23.
    Sprung CL, Cohen SL, Sjokvist P, et al (2003) End-of-life practices in European intensive care units: the Ethicus Study. JAMA 290:790–797PubMedCrossRefGoogle Scholar
  24. 24.
    Wenger NS, Carmel S (2004) Physicians’ religiosity and end-of-life care attitudes and behaviors. Mt Sinai J Med 71:335–343PubMedGoogle Scholar
  25. 25.
    Poulton B, Ridley S, Mackenzie-Ross R, Rizvi S (2005) Variation in end-of-life decision making between critical care consultants. Anaesthesia 60:1101–1105PubMedCrossRefGoogle Scholar
  26. 26.
    Martin DK, Singer PA, Bernstein M (2003) Access to intensive care unit beds for neurosurgery patients: a qualitative case study. J Neurol Neurosurg Psychiatry 74:1299–1303PubMedCrossRefGoogle Scholar
  27. 27.
    Osborne ML (1992) Physician decisions regarding life support in the intensive care unit. Chest 101:217–224PubMedGoogle Scholar
  28. 28.
    Studdert DM, Mello MM, Burns JP, et al (2003) Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Intensive Care Med 29:1489–1497PubMedCrossRefGoogle Scholar
  29. 29.
    Fins JJ, Solomon MZ (2001) Communication in intensive care settings: the challenge of futility disputes. Crit Care Med 29(Suppl 2):N10–N15PubMedCrossRefGoogle Scholar
  30. 30.
    Azoulay E, Sprung CL (2004) Family-physician interactions in the intensive care unit. Crit Care Med 32:2323–2328PubMedGoogle Scholar
  31. 31.
    Breen CM, Abernethy AP, Abbott KH, Tulsky JA (2001) Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 16:283–289PubMedCrossRefGoogle Scholar
  32. 32.
    Breslin JM, MacRae SK, Bell J, Singer PA (2005) Top 10 health care ethics challenges facing the public: views of Toronto bioethicists. BMC Med Ethics 6:E5PubMedCrossRefGoogle Scholar
  33. 33.
    Redman BK, Fry ST (2000) Nurses’ ethical conflicts: what is really known about them? Nurs Ethics 7:360–366PubMedGoogle Scholar
  34. 34.
    Guidelines for intensive care unit admission, discharge, and triage (1999) Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med 27:633–638CrossRefGoogle Scholar
  35. 35.
    Rocker G, Dunbar S (2000) Withholding or withdrawal of life support: the Canadian Critical Care Society position paper. J Palliat Care 16(Suppl):S53–S62PubMedGoogle Scholar
  36. 36.
    Consensus report on the ethics of foregoing life-sustaining treatments in the critically ill (1990) Task Force on Ethics of the Society of Critical Care Medicine. Crit Care Med 18:1435–1439CrossRefGoogle Scholar
  37. 37.
    Johnson KS, Elbert-Avila KI, Tulsky JA (2005) The influence of spiritual beliefs and practices on the treatment preferences of African Americans: a review of the literature. J Am Geriatr Soc 53:711–719PubMedCrossRefGoogle Scholar
  38. 38.
    Wojtasiewicz ME (2006) Damage compounded: disparities, distrust, and disparate impact in end-of-life conflict resolution policies. Am J Bioeth 6:8–12PubMedGoogle Scholar
  39. 39.
    Ventres W, Nichter M, Reed R, Frankel R (1993) Limitation of medical care: an ethnographic analysis. J Clin Ethics 4:134–145PubMedGoogle Scholar
  40. 40.
    Citizenship and Immigration (2003) Immigrants in Canada: Census 2001 Highlights. Available at: Accessed Dec 2006
  41. 41.
    Dlugacz YD, Stier L, Lustbader D, Jacobs MC, Hussain E, Greenwood A (2002) Expanding a performance improvement initiative in critical care from hospital to system. Jt Comm J Qual Improv 28:419–434PubMedGoogle Scholar
  42. 42.
    Christian M (2006) Report from the Adult Critical Care A/D/T Working Group. Ontario Health Plan for an Influenza Pandemic. Ontario Ministry of Health and Long Term Care. Available at: Accessed Dec 2006
  43. 43.
    Osterholm MT (2005) Preparing for the next pandemic. N Engl J Med 352:1839–1842PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media Inc. 2007

Authors and Affiliations

  • N. M. Danjoux
    • 1
  • L. Hawryluck
    • 2
  1. 1.Policy Analyst — Critical Care StrategyMinistry of Health and Long-Term CareTorontoCanada
  2. 2.Critical Care DepartmentToronto General HospitalTorontoCanada

Personalised recommendations