Transcript Is Conscientious Objection a Way to Manage Moral

Tough Calls:
Ethical Decisions and Moral Distress
for the Healthcare Team
Dimensions in Critical Care
April 5, 2016
Don C. Postema, Ph.D.
Program Director of Medical Bioethics
HealthPartners
Overview
1. What and where is moral distress?
2. The genealogy of moral distress: what does
history show us?
3. What types of moral distress occur in the
critical care setting, and why?
4. Living with moral distress: how?
What Is Moral Distress? A Case
Gene was a registered nurse in the intensive care
unit (ICU) at a large city hospital. Mrs. Smith was
admitted to his unit with chest pain and shortness of
breath. At 80, Mrs. Smith had no significant past
medical history, apart from mild hypertension and
arthritis. Upon admission, she was hypoxic and
subsequently received supplemental oxygen. Otherwise
her vital signs were stable.
•
Ann Hamric, “Moral Distress and Nurse-Physician Relationships,” AMA Journal of Ethics, 12:1 (2010).
Soon after admission, Mrs. Smith’s hemodynamic
status began to deteriorate. She became hypotensive
and had evidence of cardiogenic shock and altered
mental state. Dr. Hammond, the attending physician,
updated Mrs. Smith and her family on her condition,
and, considering her cardiogenic shock, recommended
taking her to the cath lab. He argued that, despite her
advanced age, Mrs. Smith had no significant underlying
comorbidities and had been in good health. He believed
that opening a closed artery could make her feel better
and would give her the best chance at living the longest.
Considering Mrs. Smith’s previous health and the
promised benefit of catheterization, her three children
decided to consent to this invasive procedure.
Shortly after her catheterization, Mrs. Smith went into
respiratory distress, and flash pulmonary edema was
diagnosed. She was intubated and sedated, and Gene became
her primary caretaker, making sure her vital signs were good,
administering medications, and speaking with her three
children about her care. Mrs. Smith had completed an
advance directive several years before, expressing her desire
not to be resuscitated or kept alive on a ventilator if she were
“in the process of dying.” Dr. Hammond was confident that
Mrs. Smith would recover, arguing that the intubation was
temporary and that she would be extubated when her lung
function improved. Consistent with his prediction, Mrs. Smith
improved and was extubated the following morning. Gene had
a talk with Mrs. Smith, in which she stated that she felt
terrible, thought it was close to her time, and was at peace
with what was to come.
Although stable for a short period during which the
conversation occurred, Mrs. Smith soon relapsed, her vital
signs destabilized, and she was reintubated. That night, she
spiked a fever. Antibiotics were started, and the lab cultures
revealed Streptococcus pneumoniae as the cause of infection.
During this time, Mrs. Smith consistently shook her head “no”
whenever new drugs were introduced or intravenous lines
were inserted. Realizing her discomfort, Gene asked Mrs.
Smith directly if she wanted to continue life-saving measures,
and she continued to shake her head “no.” Gene reported this
to Dr. Hammond, but he was certain she would recover; the
antibiotics appeared to be working, he said, and her ejection
fraction was steady at 45 percent. Dr. Hammond believed that
Mrs. Smith’s desire to discontinue treatment only reflected her
misunderstanding of the situation. She remained a “full code.”
The next day, Mrs. Smith’s children told both Gene
and Dr. Hammond that their mother was clear in her
advance directives and that she would not want to be
kept alive on a ventilator. Mrs. Smith’s heart
measurements were steadily declining, as were her vital
signs and consciousness. Dr. Hammond maintained his
hope for her recovery, so the family backed off, trusting
his medical judgment.
Gene was not sure what to do. When a similar
situation had occurred the year before, Gene had called
an ethics consult, the result of which ultimately favored
the physicians. At that time, the hospital instituted a
policy stating that only physicians or family members
could call ethics consults.
Gene wanted to voice his concern to Dr. Hammond again
or approach another administrator, but feared getting in
trouble with his supervisors for being unprofessional or
impeding patient care. He felt that he understood Mrs.
Smith’s situation better than anyone, because he had cared
for her since her hospitalization and had talked with her
during the brief period during which she was off the
ventilator. He saw himself as Mrs. Smith’s advocate, and was
deeply troubled to see her suffering so greatly and, in his
mind, needlessly. Gene reflected upon how often he ran into
situations like this in the ICU, and wondered what he could
do about it.
Initial Diagnosis
• With what features of Gene’s experience do
you resonate? Why?
• What do you think should have been done?
Why?
• Was there moral uncertainty in this case?
• Moral conflict?
• Moral distress?
Moral Distress Isn’t Moral Uncertainty
Moral uncertainty is not being clear about a moral
value(s) or how to apply a value(s) to a specific
context or population.
For example, (1) discussions concerning how to think of
justice and the rights of the disabled. Should the
disabled be treated equally (equal rights and
responsibilities to those not currently disabled), or
unequally (special considerations or preferential
treatment because they are disabled)? (2) If an
intervention requested by a family is not of benefit to a
patient, is it permissible to provide it?
Moral Distress Isn’t Moral Conflict
Moral conflict occurs, typically, when two or
more moral values cannot be realized in a
given context and a hard choice is required.
For example, (1) do you honor confidentiality
when it could lead to harm to a third party?
(2) Should you report an error by a fellow
professional who is a friend? (3) Should
quality of life trump length of life?
Some Degree of Moral Stress Is Normal
Moral uncertainty and moral conflict are part
and parcel of the moral life of a responsible
moral agent. Moral stress is associated with a
morally responsible life. While this may become
more intense, there are resources which lessen
its impact and enable one to live with it. “Moral
engineering” may succeed in managing stress if
one’s moral fiber is strong and resilient.
What Is Moral Distress? Origins
“... moral distress arises when one knows the
right thing to do, but institutional constraints
make it nearly impossible to pursue the right
course of action.” One’s sense of moral
responsibility cannot be acted upon because of
internal (personal) constraints or external
(institutional) barriers.
•
Andrew Jameton, Nursing Practice: The Ethical Issues. New Jersey: Prentice Hall, 1984.
Examples of internal constraints are a lack of
assertiveness, self-doubt, socialization to
follow orders, perceived powerlessness, and a
lack of understanding the full situation.
Aristotle identified “weakness of will”
(akrasia), knowingly doing what one has less
reason to do instead of what one has more
reason to do.
External constraints may include:
•inadequate staffing
•hierarchies within healthcare systems
•lack of collegial relationships and communication
•lack of administrative support
•policies and priorities that conflict with care needs
•compromised care due to pressures to reduce costs
•the fear of litigation.
Moral Distress: Next Generation
Jameton later distinguished two stages of moral distress:
“Initial distress involves the feelings of frustration, anger,
and anxiety people experience when faced with
institutional obstacles and conflict with others about
values.
Reactive distress is the distress that people feel when they
do not act upon their initial distress.” Symptoms include
feelings of powerlessness, guilt, self-criticism and low self
esteem, as well as physiological responses like crying,
loss of sleep, nightmares, and loss of appetite.
•
“Dilemma of Moral Distress: Moral Responsibility and Nursing Practice,”
WHONNS Clinical Issues in Perinatal and Women’s Health Nursing, 4:542-551 (1993).
The Diaspora of Moral Distress
Originally, most discussions of moral distress focused on
nurses, especially nurses in intensive care settings.
Corley (1995) developed the Moral Distress Scale to assess
nurses’ experience of moral distress in 38 clinical
situations. It looked at factors such as:
• working with staff who are not competent,
• being refused the role of advocating for the patient,
• therapeutic obstinacy on the part of patients and their
families, and
• disregarding a patient’s autonomy.
M. Corley, “Moral Distress of Critical Care Nurses,” American Journal of Critical Care 4 (1995).
Moral distress has since been studied in:
• Medical students and residents
• Rehabilitation therapists
• Respiratory therapists
• Pharmacists
• Psychologists
• Social workers
• Chaplains
• Physicians
Epstein, E.G., Delgado, S., (Sept 30, 2010)
"Understanding and Addressing Moral Distress"
OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 3
Selected Findings of Interest
• Younger nurses seem to be more profoundly affected by
moral distress.
• In one study, female nurses reported higher levels of
moral distress than male nurses.
• Some studies show African Americans and Asians
experience less moral distress, some show they
experience more.
• Religious commitment may be associated with less moral
distress.
• Having had formal ethics training increases awareness of
moral distress (but ignorance is not bliss).
Genealogy of Moral Distress: The
Death of a Concept?
“The notion itself is conceptually flawed and suffers
from both theoretical and practical difficulties. Nursing
research investigating moral distress is also problematic
on account of being methodologically weak and
disparate. Moreover, the ultimate purpose and
significance of the research is unclear. In light of these
considerations, it is contended that the notion of moral
distress ought to be abandoned…”
•
Johnstone, M.J., and Hutchinson, A. “’Moral Distress’ – Time to Abandon a Flawed Nursing Construct?”
Nursing Ethics, December, 2013.
Pre-Mortem Reports Exaggerated
• A literature search in PubMed yielded more than 500
articles related to moral distress in the last 5 years
• Reports of the demise of the concept are
exaggerated as long as:
– There are health care professionals who are
constrained and restrained from doing what they
know is morally right, and
– Advancement in the health care professions
requires research and publication.
Where Is Moral Distress in the ICU?
• “Moral distress occurs when a healthcare
professional believes he or she knows the
ethically correct action but cannot follow that
action because of an interpersonal,
institutional, regulatory or legal constraint.”
• “We believe that team-based models present
an opportunity for moral distress study.”
•
Bruce, Miller, Zimmerman, “A Qualitative Study Exploring Moral Distress in the ICU Team: The Importance
of Unit Functionality and Intrateam Dynamics,” CritCareMed 43:4 (April, 2015).
Moral Distress in the ICU: Recent
Findings
• Moral distress is higher in ICU nurses and other nonphysician professionals (social work, respiratory
therapists, pharmacists) than in physicians.
• Moral distress is lower with older age for other nonphysician professionals but greater with more years
of experience in nurses.
• Moral distress is associated with tendency to leave
the job.
•
Dodek, et. Al., “Moral Distress in Intensive Care Unit Professionals is Associated with Profession, Age, and
Years of Experience,” Journal of Critical Care 2015.
Sources of Moral Distress in the ICU
In the ICU, there are three areas involving
discordance because of misalignment in prognostic
expectations and treatment goals:
1. Disagreement between a healthcare professional
and a patient or surrogate decision maker.
2. Disagreement between family members.
3. Disagreement between healthcare professionals
about a patient’s care.
The greatest of these is…
•
Bruce, et al, 825-826.
Intrateam Discordance and Moral
Distress: When Most Likely to Occur?
• Situations involving initiation or maintenance
of non-beneficial life-sustaining treatments
• Situations involving lack of full disclosure
about treatments, creating perceived
compromises in the informed consent
processes
•
Bruce, et al, 826.
More on Intrateam Discordance
“In this study, RNs experienced more moral
distress than MDs and perceived less collaboration
than their MD colleagues. They perceived their
ethical environment as more negative, and they
were less satisfied with the quality of care provided
on their units than were MDs. Provider assessments
of quality of care were strongly related to
perception of collaboration.”
•
Hamric and Blackhall, “Nurse-Physician Perspectives on the Care of Dying Patients in
Intensive Care Units,” CritCareMed 35:2 (2007)
How Not to Manage Moral Distress
Maladaptive Behaviors
• The pas-de-deux: a dance in which two
discordant views are presented to the family.
• Combat: direct and indirect fighting.
• Desensitization: feeling ineffectual and
withdrawing or detaching. Physicians typically
detach, nurses typically embed.
•
Bruce, et al, 827-828.
Responses to Moral Distress
Responses to Moral Distress:
External Dimensions
• When constrained by external factors or conditions, a
critical analysis of those structures may be of value.
• For example:
• Why were nurses the original focus of moral distress
research?
• Why do medical students and residents report higher
levels of moral distress?
• Are authoritarian, hierarchical structures implicated in
moral distress experienced as constraint?
• What of the effect of structural injustices such as
sexism?
Managing Moral Distress:
Internal Dimensions
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Vent to colleagues
Utilize mentoring networks
Build team cohesion
Improve communication
Request an ethics consult
Develop alternative practices
– Collaborative assessments of futile treatments by
physicians and nurses are more accurate.
–
Neville, et. Al., “Concordance of Nurses and Physicians on Whether Critical Care Patients are
Receiving Futile Treatment,” AJCC 2015.
Develop the Virtue of Moral Courage
• A virtue is a disposition or capacity, developed
through habituation (like a skill), by which a person is
able to realize a good within a social role or practice.
• Moral courage, one of the virtues (others include
loyalty, generosity, care, temperance, etc.), is a
disposition which can be strengthened so as to
counter weakness of moral will.
• Moral courage is a capacity, not a given, which
requires deliberate cultivation and exercise.
Moral Courage Resources
• Collegiality
• Ethics Committees and the Ethics Consult
Service
• Continuing Education
• Organizational Policies and Support
• Professional Society Policies
• Community Forums
Develop Moral Resilience
• Moral resilience “involves choosing how one will
respond to ethical challenges , dilemmas and
uncertainty in ways that preserve integrity, minimize
one’s own suffering, and allow one to serve with
highest purpose.”
• “Moral resilience is a concept that is gaining
prominence as a way to transform the profound
despair and powerlessness associated with morally
distressing situations.”
•
Cynda Hylton Rushton, “Moral Resilience: A Capacity for Navigating Moral Distress in Critical Care,”
AACN Advanced Critical Care, 2016.