1. Ethical challenges in medicine:
   • The practice of medicine has always faced ethical challenges regarding key decisions and boundaries of life.
   • New technologies in medicine, such as life support and genetic manipulation, raise new ethical questions.
   • Changes in society and its values also contribute to new ethical challenges.
2. Ethics in intensive care units (ICUs):
   • ICUs are often the source of ethical challenges due to conflicts surrounding death.
   • Death and brain death, once firmly fixed concepts, are now being questioned.
   • Patient autonomy in requesting life-prolonging therapies adds to the ethical challenges.
   • Surrogate decision-making for patients who are unable to express their wishes is another ethical dilemma.
3. Goals of care and medical decision making:
   • Shared decision making between patients and physicians is the ideal approach.
   • In the ICU, shared decision making becomes more complex due to the nature of the care.
   • Advance care planning and advance directives help guide medical care when patients lose decision-making capacity.
   • Choosing a surrogate decision maker is important, preferably someone chosen in advance by the patient.
   1. Surrogate decision making:
   • In some cultures, the next of kin is often the surrogate decision maker.
   • Legal and ethical grounds for surrogates vary, and the patient's choice is most respected.
   • Documentation of advance directives clarifies the role of the surrogate and the patient's agreement.
   • In the absence of advance directives, decision makers should use a reasonable-person or best-interest standard.
4. Types of advance directives:
   • Living wills are restricted to terminal patients and focus on forgoing medical treatments.
   • Durable power of attorney for health care gives legal authority to a named surrogate.
   • Advisory documents, such as values histories, provide general information about health care preferences.
   1. Conclusion:
   • Ethical challenges in medicine continue to evolve with new technologies and changes in society.
   • ICUs are particularly susceptible to ethical dilemmas surrounding death and patient autonomy.
   • Shared decision making and advance directives help navigate these challenges.
   • The choice of a surrogate decision maker is crucial, respecting the patient's preferences.
5. Advance Directives:
   • Advance directives have not achieved wide popularity due to lack of specificity and questions around patient's understanding and decisional capacity.
   • A code status is a limited form of advance directive specifically addressing preferences regarding CPR and other measures in the event of a cardiac arrest.
   • DNR status in ICU patients may indicate acceptance of limits of medical science, while refusal may indicate an incomplete understanding of the illness.
6. Common Errors in Code Status Discussions:
   • Failure to convey accurate information about the likelihood of success after resuscitation.
   • Failure to address post-resuscitation issues and assuming patient wishes to continue all care.
   • Not identifying a preferred surrogate decision maker given the risk of temporary or permanent brain injury after resuscitation.
7. Questions for Advance Directives Discussions:
   • In the event of a cardiac arrest, does the patient want the health care team to attempt resuscitation?
   • If the patient becomes incapacitated, who does the patient want to make decisions on their behalf?
   • Under what circumstances would the patient want to discontinue life-sustaining care if significantly impaired after resuscitation?
8. Informed Decision Making and Autonomy:
   • Informed decision making requires patients to have enough information to weigh the risks and benefits of medical interventions.
   • Patients need information about the illness, treatment effectiveness and risks, and likelihood of success.
   • Decision making must be voluntary and free from coercion.
   • In the intensive care unit (ICU), the decision maker is often a surrogate who should have access to relevant information.
9. Special Considerations for Informed Consent in the ICU:
   • Surrogates should have access to relevant information for informed consent but should not be given confidential information not related to the decision at hand.
   • Adequacy of a designated surrogate should be questioned in certain situations.
10. Surrogate Decision Making:
    • Surrogate decision making should align with the patient's wishes or involve outside assistance.
    • Ethics consultation can help resolve conflicts and improve patient outcomes.
11. Medical Futility:
    • Defining medical futility is challenging due to advancements in medicine.
    • Modern interventions make it possible to keep patients alive in situations where death was once inevitable.
12. Conflicts of Interest:
    • Professional societies recommend using the term 'requests for inappropriate care' instead of 'futility'.
    • Institutions should proactively communicate and involve expert consultants to prevent conflicts.
    • Conflicts regarding potentially inappropriate treatments should be managed through fair conflict resolution processes.
13. Controversies from New Technology:
    • Advances in technology have introduced ethical challenges in critical care.
    • Technologies like ECMO and CVVH raise issues of distributive justice and nonmaleficence.
    • Postmortem gamete retrieval raises questions about informed consent and conflicts of interest.
    • The increasing interest in complementary and alternative medicine presents ethical issues.
14. Ethics in Critical Care:
    • Ethics in critical care are based on the principles of beneficence, nonmaleficence, autonomy, and justice.
    • In the United States, competent patients have the right to make their own decisions.
    • Advance care planning and shared decision making are important processes in critical care.
15. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: A randomized controlled trial:
    • A seminal randomized controlled trial that demonstrated reduced hospital and ICU length of stay and decrease in “nonbeneficial treatment” in patients who received ethics consultation while in the ICU.