ethics in the nicu: a nursing perspective elizabeth gingell epstein, phd, rn associate professor of...
TRANSCRIPT
Ethics in the NICU: A Nursing Perspective
Elizabeth Gingell Epstein, PhD, RN
Associate Professor of Nursing
UVA School of Nursing and Center for Biomedical Ethics and Humanities
Disclosure statement: I have nothing to disclose
Objectives
Identify 2 common ethical dilemmas encountered by nurses in the NICU.
Define the concept of moral distress and discuss 2 strategies to address the phenomenon.
Describe 2 benefits and challenges of a monthly collaborative complex case conference.
Ethical challenges we all see:
I. Frameworks for evaluating ethical dilemmasII. What nursing brings to the tableIII. Ethics consultation
Ethical challenges that are harder to see (but just as important):
IV. “Microethics”V. Systems problemsVI. Moral distressVII. Moral distress consultation/complex case discussion
Challenges for nursing in a changing environmentVIII.AccountabilityIX. Team collaborationX. But not courage
Ethical challenges we all see
Resuscitation in the DR Limits of viability Acceptability of offering ECMO, dialysis,
transplant Limits of parental authority
www.neonatology.org/tour/sociology.html
A different framework for evaluating ethical dilemmas
Principles Relationship-based reasoning
Beauchamp & Childress (2009); Gilligan (1987)
What nurses bring to the table
• 24/7 vigilance• The long-term view• Different types of knowing• A view from the middle• A sense for the subtle• Preventive approach
Anspach (1993) Epstein (2012) Frick (2003)
Ethical challenges that are harder to see: Microethics: A closer view Truog (2015)
Systems issues: Repetition, Routinization, Silos
Chambliss (1996); Shannon (1997); Maxfield et al. (2005)
Moral distress
“The experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards.” -Varcoe et al, 2012
“The judgment that one is not able, to differing degrees, to act on one’s moral knowledge about what one ought to do.” -Thomas & McCullough, 2015
www.besthealthcarerates.com
“Attending…coding a baby with a pulmonary hemorrhage and the endotracheal tube filled with blood, oscillating with chest compressions, and I was thinking, ‘This is wrong. This is so wrong.’”
--NICU Resident
Epstein (2008)
Common root causes
Hamric, Borchers & Epstein (2012)
Providing unnecessary/futile treatment
Prolonging the dying process through aggressive treatment
Inadequate informed consent
Working with colleagues who are not as competent as care requires
Lack of consensus re: treatment plan
Lack of continuity of care
Inappropriate use of resources
Providing care that is not in the best interest of the patient
Providing inadequate pain relief
Providing false hope
Lack of truth-telling
Disregard for patient wishes
External constraints
Inadequate communication among team members
Differing inter- or intra-professional perspectives
Inadequate staffing
Lack of administrative support
Tolerance of disruptive, intimidating, or abusive behavior
Pressure to reduce costs or pressure from insurance companies
Hierarchies within the healthcare system
Lack of involvement of team members in decision making
Policies or priorities that conflict with care needs
Fear of litigation
Hamric, Borchers & Epstein (2012)
Intent to leave
“I quit nursing last month for exactly this reason. The stress on caring nurses (and doctors) is unbearable. Competent nurses feel frustrated at their own powerlessness, frightened of being sued, and heart-broken about what is being done to patients for all the wrong reasons. Furthermore, the healthcare crisis is so severe that all excellent practitioners worry constantly about mistakes that occur every day simply because of the chaos in the system itself, not because anyone did anything incompetent…I came to nursing because I care so deeply about patients, but I left it because I want work that doesn’t hurt me as a person.”
--Response to P. Chen’s (2009) “When nurses and doctors can’t do the right thing.”
Moral Distress Consultation & Complex Case Discussion
Recognizing moral distress as legitimate
Avenues to address:Within unitWithin organizationFocus on coping/resilienceFocus on action
Complex Case Discussion
Arose from moral distress consultation
Ethical and morally distressing issues
Monthly multidisciplinary team meetings
Neutrality, elephants on the tableHamric, Borchers & Epstein (2012)
Challenges for nurses
Accountability
Responsibility
Team collaboration
But not courage
Thank you
References
Anspach (1993). Deciding who lives. Los Angeles: University of California Press.
Beauchamp & Childress (2009). Principles of biomedical ethics. New York, NY: Oxford University Press
Chambliss (1996). Beyond caring: Hospitals, nurses, and the social organization of ethics. Chicago: University of Chicago Press
Chen (2009). When doctors and nurses can’t do the right thing. NY Times
Epstein (2008). End-of-life experiences of nurses and physicians in the newborn intensive care unit. J Perinatol 28: 771-778.
Epstein & Hamric (2009). Moral distress, moral residue, and the crescendo effect. J Clin Ethics 20(4): 330-342.
Epstein (2012). Preventive ethics in the ICU. AACN Advanced Critical Care 23(2):217-224.
Frick (2003). Medical futility: Predicting outcome of intensive care unit patients by nurses and doctors: A prospective comparative study. Crit Care Med 31:456-461.
ReferencesGilligan (1987). Moral orientation and moral development. In Kittay & Meyers Women and Moral Theory. Savage, MD: Rowman & Littlefield
Hamric, Arras, Mohrmann (2015). Must we be courageous? Hastings Center Report 45(3): 33-40.
Hamric, Borchers, Epstein (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research 3(2):1-9
Maxfield et al. (2005). Silence kills: The seven crucial conversations for healthcare. Provo, Utah: VitalSmarts.
Shannon (1997). The roots of interdisciplinary conflict around ethical issues. Crit Care Nursing Clinics 9(1): 13-28.
Thomas & McCullough (2015). A philosophical taxonomy of ethically significant moral distress. J Med Philos 40:102-120.
Truog et al. (2015). Microethics: The ethics of everyday clinical practice. Hastings Center Report, 45(1): 11-17.
Varco et al. (2012). Moral distress: Tensions as springboards for action. HEC Forum 24:51-62.
Photos from www.morguefile.com