At some hospitals, ethics consultations are viewed as clinical orders and can only be requested by physicians. “This limits a nurse, or any other member of the healthcare team, including the patient, from exercising the right to pursue an ethics consultation,” says Liz Stokes, JD, MA, RN, director of the American Nurses Association’s Center for Ethics and Human Rights in Silver Spring, MD.
Many nurses are eager for ethics advice, but they’re not always comfortable raising a concern on their own, says Stokes. Some lack awareness that a particular issue is ethical in nature. Others don’t see the value of ethics involvement in a case, or simply don’t know how to request a consult.
“Given that some nurses are unable to recognize an ethical dilemma or may not know how to make an ethics consultation, education and awareness are essential in encouraging nurses to do so,” says Stokes. The following are some approaches:
• Perform ethics consultation rounds, including nursing.
Nurses will see the ethics consultant on the unit on a regular basis. “The mere presence alone can spark conversation and raise awareness of the value of the ethicist,” says Stokes.
• Ethicists can make it known they’re open to providing consultations to healthcare providers anonymously.
“Although this does not necessarily speak to a culture of safety and transparency, it can be used as a mechanism for a nurse’s voice to be heard without the fear of risk of reprisal,” says Stokes.
• Reward nurses who do seek ethics consultations.
“Some hospitals have ‘moral courage’ awards or awards that recognize a nurse’s advocacy efforts, especially in difficult situations or ethical dilemmas,” says Stokes.
Nurses from the ethics committee and the ethics service at Houston-based MD Anderson Cancer Center instituted a Nursing Ethics Patient-Aligned Care Team. The group performs nursing ethics rounds in both inpatient settings and outpatient clinics. Nurses are able to discuss an ethical issue generally or related to a particular patient.
“We also have an ethicist attend the nursing and interdisciplinary meetings about patients so that recommendations can be given,” says Colleen M. Gallagher, PhD, LSW, FACHE, chief and executive director of MD Anderson’s Section of Integrated Ethics in Cancer Care. This approach hasn’t increased the number of requested consults. “It does however, give nurses an opportunity to raise their concerns and have them addressed,” says Gallagher.
Some nurses need help with bringing their concerns to physicians or other clinicians on the healthcare team. “It is about coaching for good communication, as much as it is about finding the right thing to do for each patient,” says Gallagher.
Physicians sometimes become upset because they feel their judgment is being questioned by nurses. “We also hear stories of how nurses are hard on each other and do not want to be seen as ‘rocking the boat,’” says Gallagher.
Often, the way in which the concern is raised is the reason for less-than-professional responses. Phrases such as “We have a problem” can take a negative turn. Gallagher suggests that nurses instead say, “Doctor, it seems that (patient name) is having a hard time with…. How can nurses help?”
The following steps are taken once a nurse raises an ethical concern:
• the ethicist contacts the physician and lets him or her know that a concern exists;
• the ethicist helps with the communication among the team members, or with decision makers.
“We include nurses and physicians together as presenters when conducting ethics education of difficult cases,” adds Gallagher. “This highlights the interdisciplinary team approach.”
If nurses report a conflict within the clinical team, ethicists can help by swiftly providing a trusting environment for deliberation.
“As part of the ethicist’s assessment, it is important to recognize that some ethical issues are unique to nurses,” says Stokes. While physicians often make the treatment decisions, nurses are responsible for actually performing the tasks involved. Nurses may be asked to continue life-sustaining treatment where it is deemed to be of no clinical benefit. “This can be contrary to a nurse’s moral belief or integrity, especially if that treatment is causing harm or suffering to the patient,” says Stokes.
Ethicists at Dartmouth-Hitchcock Medical Center in Lebanon, NH, use these approaches to encourage nursing involvement with ethics:
• they explicitly invite nurses to request consults;
• nursing leadership is included on the clinical ethics committee;
• representatives of the clinical ethics committee attend nursing meetings;
• clinical ethicists provide regular educational conferences to nursing staff;
• nurses are included in ethical discussions during consultations.
“The availability of the service in general, and to nurses in particular, is clear,” says Tim Lahey, MD, MMSc, chair of the Dartmouth-Hitchcock clinical ethics committee.
Coaching on communication strategies by phone, and talking through the ethical issues in a particular case, is sometimes enough. “We simply help them identify effective communication behaviors that allow them to raise a concern in a team conversation,” says Lahey.
In these cases, ethicists don’t need to be directly involved. “Ideally, such interactions would occur in a healthy organizational context, in which nurses occupy high positions of leadership at many points in the organization — so that historical disrespect of the contributions of nurses is fully and publicly absent,” notes Lahey.
A nurse recently called ethicists because she felt the treatment plan was more aggressive than a delirious patient had said she wanted while in a clearer state of mind. The nurse acknowledged that she hadn’t brought it up with the patient’s physician. Instead of calling a formal consult, the ethicist and nurse brainstormed about effective ways to raise the issue. Perhaps she could ask clarifying questions on rounds, or ask other nurses if they had the same concerns.
“I assured the nurse that I could back her up if that didn’t go well,” says Lahey. “A good conversation ensued, and concerns about ethical problems evaporated.”
It turned out the physician had spoken with both the patient and a loved one about their preferences, but hadn’t kept the nurse in the loop. “The episode was a good example to both of them to stay in close collaboration,” says Lahey.
• Colleen M. Gallagher, PhD, LSW, FACHE, Chief and Executive Director, Section of Integrated Ethics in Cancer Care, MD Anderson Cancer Center, Houston. Email: CMGallagher@mdanderson.org.
• Tim Lahey, MD, MMSc, Chair, Clinical Ethics Committee, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Phone: (603) 650-6060. Email: Timothy.Lahey@Dartmouth.edu.
• Liz Stokes, JD, MA, RN, Director, Center for Ethics and Human Rights, American Nurses Association, Silver Spring, MD. Phone: (301) 628-5394. Email: firstname.lastname@example.org.