Executive Summary
Ethical conflicts within the clinical team may involve patients without advance directives, differing opinions on continuation of life-sustaining interventions, and residents feeling voiceless. To prevent clinicians’ moral distress, bioethicists can:
- Do “real-time” training so conflicts can be addressed immediately.
- Hold ongoing conversations on the care of terminally ill patients.
- Encourage attendings to ask nurses’ opinions on shifting to comfort measures.
Ethical conflicts within a care team are not uncommon — nor are they particularly surprising. “Providers have their own individual set of values and moral commitments,” notes Autumn Fiester, PhD, director of the Penn Clinical Ethics Mediation Program and faculty in the Department of Medical Ethics & Health Policy at Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
Fiester says the question is how to navigate such conflicts constructively, without creating “moral winners and losers.”
Bioethicists can most effectively address professional conflicts if they’re seen as a member of the team, says Nneka O. Sederstrom, PhD, MPH, FCCP, director of the Center for Ethics at MedStar Washington Hospital Center in Washington, DC. “When the team sees you as a needed and respected resource, they are more willing to engage in conversation,” Sederstrom says. “The bottom line is, ethics consultation teams need to be trusted.”
Rounding allows bioethicists to do “real-time” training on cases where conflict is likely. “The team addresses issues immediately instead of holding up care,” says Sederstrom. Here are some common situations involving ethical conflicts that can cause moral distress within the clinical team:
• A patient who lacks decision-making capacity has no advance directive.
This is one of the most common clinical team conflicts encountered by Paul Hofmann, DrPH, FACHE, when conducting ethics rounds. Hofmann is president of Hofmann Healthcare Group, a Moraga, CA-based consulting firm specializing in healthcare ethics, and a former hospital CEO.
“Nurses believe one or more physicians are providing non-beneficial invasive treatment, and family members are receiving mixed messages,” he says.
Hofmann utilizes these strategies:
--determining which physician is responsible for coordinating and leading the treatment decision-making process,
--clarifying the patient’s prognosis,
--understanding the reasons for concerns expressed by nurses,
--facilitating a meeting to reconcile conflicting opinions,
--obtaining an agreement regarding which physician will be the primary communicator with the family, and
--arranging a meeting with family members and clinicians to discuss the care plan.
• Palliative sedation is being used in a terminal patient whose suffering cannot otherwise be relieved.
“It is certainly difficult to watch a patient’s respiratory drive slow down and become agonal,” says Dennis M. Sullivan, MD, MA (Ethics), director of the Cedarville (OH) University’s Center for Bioethics.
Though emotionally difficult, it is important to treat the patient who has expressed wishes for only comfort care. “Inappropriately reacting to the emotional distress of caregivers may merely prolong the dying process,” says Sullivan. “A skilled physician can help families and nurses better understand this difficult form of palliative treatment.”
It is essential to hold ongoing conversations with anyone involved in the care of the patient from the start of the palliative sedation process, says Julie M. Aultman, PhD, director of the Bioethics Certificate Program at Northeast Ohio Medical University in Rootstown.
“It is not uncommon for caregivers to question the goals of palliative sedation — whether to hasten death or relieve suffering — as this controversial practice has both benefits and burdens,” says Aultman.
Ethicists can identify moral conflicts that may arise. “As part of the process of palliative care, it is essential to regularly check in with caregivers to determine how they are coping with the care of their patients,” says Aultman.
• Surgeons disagree with intensivists on end-of-life care.
“This is the most common conflict we face,” says Sederstrom.
From the surgical perspective, the patient’s heart stabilizing or bowels starting to function again are signs of improvement. “But the intensivist sees a global disaster — every other organ is failing,” says Sederstrom. This leads to interprofessional conflict on what’s in the patient’s best interest. “We get called often to address these issues,” says Sederstrom.
• Nurses and physicians disagree over the need to shift to comfort care measures.
Nurses spend much more time at the bedside than physicians do. “So they feel they have a better overall understanding of what the patient’s condition is,” says Sederstrom. Typically, nurses are the first to understand the patient is dying. Thus, they advocate for shifting to comfort care measures sooner.
“Many times, the physicians are going more by the lab values reported by the residents than actual experience from patient examination,” says Sederstrom.
It is typically during rounds that the nurses bring up their discomfort with continued interventions. “It is a good attending who asks for their opinion,” says Sederstrom.
Ethicists can help facilitate any disagreement or conflict that may arise. “There have been a few cases where the nurse was incorrect and continuing to be aggressive was the right path,” notes Sederstrom. “These cases always make for great discussion.”
• A resident feels unable to voice his or her position due to institutional hierarchy.
One OB/GYN resident experienced moral distress after a court order was obtained, overriding the rights of a woman to refuse a cesarean section.1 “Disempowered by his status, he felt as though he was silenced by the medical team and institution,” says Aultman.
The resident believed the right approach was to find out why the patient was refusing the c-section, calm her fears, and ultimately support her decision for a vaginal birth despite the potential risks.
While moral distress has been cited most often in the nursing literature, notes Aultman, all types of healthcare professionals and students experience such distress. She suggests bioethicists take these approaches in such cases:
- Facilitate discussions and provide forums for healthcare professionals to express situations in which they felt as though they were disempowered.
- Hold brief real-time ethics discussions. “Invite all members of the healthcare team to weigh in on the dilemma,” says Aultman.
- A clinician believes he or she was hindered from providing emotional support to patients.
After a rape victim presented to an emergency department (ED), a nurse practitioner provided emotional support. However, her patient was hesitant to report the crime because she feared for her safety.
When the rape crisis expert came to the patient’s bedside, the patient refused to discuss the incident. “The nurse practitioner was released from her duties in caring for this patient, despite her resistance,” says Aultman.
The nurse knew that her support could help empower the patient to report the crime and ultimately secure the police protection she needed. “The nurse practitioner felt that patient care was diminished by inflexible rules and positions of power,” says Aultman.
Bioethicists are a critical resource in such cases. “It is critical that ethics education uncovers the ways healthcare institutions and persons in authority, knowingly or unknowingly, contribute to the moral distress of healthcare professionals,” says Aultman.
- Aultman J, Wurzel R. Recognizing and alleviating moral distress among obstetrics and gynecology residents. J Grad Med Educ 2014; 6(3):457–462.
- Julie M. Aultman, PhD, Director, Bioethics Certificate Program, Northeast Ohio Medical University, Rootstown. Phone: (330) 325-6113. Fax: (330) 325-5911. Email: [email protected].
- Autumn Fiester, PhD, Director, Penn Clinical Ethics Mediation Program/Faculty, Department of Medical Ethics & Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. Phone: (215) 573-2602. Email: [email protected].
- Paul B. Hofmann, DrPH, FACHE, President, Hofmann Healthcare Group, Moraga, CA. Phone: (925) 247-9700. Email: [email protected].
- Nneka O. Sederstrom, PhD, MPH, FCCP, Director, Center for Ethics, MedStar Washington Hospital Center, Washington DC. Phone: (202) 877-6211. Fax: (202) 877-3898. Email: [email protected]
- Dennis M. Sullivan, MD, MA (Ethics), Director, Center for Bioethics, Cedarville (OH) University. Phone: (937) 766-7573. Email: [email protected].
