In the wake of the 1976 Karen Quinlan case in New Jersey and other well-publicized cases, most healthcare facilities today have an ethics committee.1,2 The Joint Commission (formerly JCAHO) continues to emphasize patients' rights, admonishing facilities to create a mechanism for dealing with conflicts in the clinical setting.3 With the continuing development of technology, the ethical issues that arise are both new and old.
As ethical questions are triggered, are there mechanisms in place to manage ethical concerns, and if so, how does an organization respond? The use of bioethics consultants is becoming more widespread, although qualifications for this role aren't clearly delineated. The American Society for Bioethics and Humanities has laid the groundwork for creating qualifications by suggesting clinical competencies.4,5
Consider the kinds of issues that may prompt a request for an ethics consult and explore the reasons nurses need to be proactive in using all available resources to advocate for their patients.
At times there may be hesitation on the staff's part to consult the ethics committee. Researchers noted a perception, after interviewing nurses, that "the ethics committee has very little power [horizontal ellipsis] they will not take a stand. They will not get involved."6 Staff members may also fear retaliation or alienation from physicians who retain power in the traditionally hierarchical setting.
According to experts, moral distress results when nurses respond to ethical challenges in which they know the right course of action, but feel that the institution or colleagues make it difficult to do what's right.7 Such a situation has been found to lead to resignation and possibly moral failure with the patient as a victim.6 Experts similarly state that moral distress is caused by a situation in which the ethically appropriate action is known, but can't be acted upon.8
The sources of this moral distress are most commonly cited in ICU settings because of aggressive care of patients who aren't expected to benefit from care (medical futility), unnecessary prolongation of life, lack of clarity regarding the goals of care, and conflict with physicians or family members who are reluctant to let go. Experts have confirmed that sources of moral distress are similar in the oncology setting.9
Calling for an ethics consult
Identifying moral distress may be the easy part. It may be harder to determine when to call for an ethics consult. Nurses may need to consult their hospital's ethics committee in any of the following situations.
Futility: Staff may overuse the term "futility" when they're distressed by the burdens they associate with interventions they don't believe will help the patient in the end. Before this term is used, the particulars of the situation must be determined. What are the goals of care for the patient? A recurring scenario in ICU settings is one in which the elderly, debilitated patient with a major insult is languishing on a ventilator with progressive deterioration. Though some nurses might believe the patient's death is inevitable and continued use of the ventilator is futile, it could be argued that the ventilator is being used to oxygenate the patient (successfully) and that the goal of care is to keep him alive according to the patient's or family's wishes. This scenario could apply to several situations, such as a large stroke or an anoxic event (neither of which is theoretically terminal). Some caregivers might not agree, but at this time respect for patient autonomy supersedes our personal view. While such a situation presents as an ethical dilemma, ultimately, if carefully reviewed a tension between sound ethical principles (usually beneficence/nonmalfeasance and patient autonomy) gives way to the weightier principle of patient autonomy. On the other end of the life spectrum, neonatal ICU cases present similar questions. Multidisciplinary case discussion can provide the opportunity to reflect on all components of the dilemma. At the end of review, nurses may conclude that the parents should be the final decision makers and that they need support in this decision-making process. An ethics consultant can orchestrate this kind of discussion, resulting in clarification and education for staff.
In another case, the issue might be that the goal isn't clear and the family is receiving conflicting messages. The professional nurse abides by a code of ethics that calls on him or her to be a patient advocate.10 In this situation, the concept of futility may be sound if the family's goal is to return the patient to a baseline state. Futility is associated with the effect of care toward a specific goal. For a patient who's very debilitated and dependent on life support, further care won't return him to his baseline, and if this new state isn't acceptable to the patient, it could be considered futile. An ethics consult could be useful in clarifying expectations, mediating differences in opinions, and goal setting with timely reassessment of goals when uncertainty persists.
Interpretation of advance directives: A nurse may contact the ethics committee because a patient has a living will that says he doesn't want to be intubated, but staff intubated him. On further examination, the patient doesn't meet the criteria of his living will. Many patients will state that they wish to forego artificial nutrition or ventilators if they're permanently unconscious or terminally ill. The living will applies only if those criteria are met. For example, if the patient is very confused and admitted with pneumonia, treatment would include antibiotics and a ventilator for about 5 days. This patient will hopefully return to his baseline after treatment. An ethics consultant can review the living will, validate a concern, and educate nurses on this topic. On the other hand, if a do-not-resuscitate or do-not-intubate patient is mistakenly resuscitated, the ethics consult can also be helpful in determining the next step, focusing on the patient's rights.
Conflicts: Disagreements are bound to occur between patients, family members, healthcare team members, and physicians. Families are stressed, and there may be issues that are unresolved-perhaps communication has been suboptimal. In these cases, members of the ethics committee can be viewed as objective outsiders who will provide a fair assessment of the problems before negotiating a consensus, when possible. An ethics consult can give voice to all parties, including patients and their families.
Capacity: Questions about mental capacity are challenging, particularly within elderly, demented, mentally ill, or substance abuse populations. Healthcare workers may make false assumptions about the global abilities of mentally ill or developmentally delayed persons. When and how does a nurse overrule the patient? Nurses need to know that capacity waxes and wanes, and is task specific. The attending physician best assesses capacity, and psychiatry can be helpful if mental illness is suspected. An ethics consultant could supply more information on such a challenge.
First, do no harm
All staff members are aware of ethical dilemmas that arise in their practice. Being able to raise and discuss questions with an ethics committee can lessen the stress associated with the fear of causing harm. Likewise, truly ethical dilemmas can be addressed and resolved through the intervention of an ethics consult.
Nurses need not fear repercussions from asking questions or even disagreeing with a plan of care, as long as they're able to support a treatment goal that's ethically sound. As professionals, ethics courses would benefit nurses during their training. According to one survey, 69% of nurses had taken an ethics class.11 However, when asked about real clinical situations, nurses found it difficult to identify ethical issues.11 There's a need to remain current on ethical practices through ongoing education, which helps nurses maintain job satisfaction, act as strong patient advocates, and remain respected team members. Use of the ethics consultant as a resource can facilitate ethical practice.
1. Matter of Quinlan. 70 NJ 10. 1976; Supreme Court of NJ. [Context Link]
2. Fox E, Myers S, Pearlman R. Ethics consultation in U.S. hospitals: a national survey. Am J Bioeth. 2007;7(2):13-25. [Context Link]
3. Joint Commission. Standard RI.2.30. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, Ill: Joint Commission; 2005. [Context Link]
4. American Society for Bioethics and the Humanities. Core competencies for health care ethics consultation. Available at: http://www.asbh.org/publications/core.html. Accessed June 5, 2007. [Context Link]
5. Aulisio MP, Arnold RM, Youngner SJ, for the Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Position paper: health care ethics consultation: Nature, goals, and competencies. Ann Intern Med. 2000;133(1):59-69. [Context Link]
6. Robichaux CM, Clark A. Practice of expert critical care nurses in situations of prognostic conflict at the end of life. Am J Crit Care. 2006;15(5):480. [Context Link]
7. Corley MC, Selig P. Prevalence of principled thinking by critical care nurses. Dimens Crit Care Nurs. 1994;13(2):96-103. [Context Link]
8. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care. 2005;14(6):523-530. [Context Link]
9. Ferrell B. Understanding the moral distress of nurses witnessing medically futile care. Oncol Nurs Forum. 2006;33(5):922-930. [Context Link]
10. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Available at: http://www.nursingworld.org/ethics/code/protected_nwcoe303.htm. Accessed June 5, 2007. [Context Link]
11. Killen A. Stories from the operating room: moral dilemmas for nurses. Nurs Ethics. 2002;9(4):405-415. [Context Link]