A recent analysis of nursing requests for clinical ethics consultations revealed key concerns prompting the requests — and also what nurses felt was most important about the consults.1
“This study is part of a larger quality assessment effort. We spent several years gathering feedback from colleagues with whom we, as ethics consultants, interacted,” says Stuart G. Finder, PhD, the study’s lead author and director of the Center for Healthcare Ethics at Cedars-Sinai Medical Center in Los Angeles.
The goal was to learn how others viewed the ethics service and whether there were any specific educational or other institutional needs that ethicists needed to address.
“The underlying motivation is to be more fully accountable for the service we provide as ethics consultants,” says Finder. Some findings from the survey include the following:
• End-of-life issues were not the overwhelming majority of reasons for requesting ethics consultations. “There is a common perception that clinical ethics and end-of-life issues are closely related,” says Finder. Just 15% of requests were focused on end-of-life issues, while 39% focused on care plan concerns.
“This should not be surprising at all given the role and work nurses do,” says Finder.
Some nurses wanted support in providing what they believed was the best possible care for a patient when life-sustaining treatment was going to be withdrawn. Other nurses felt caught in the middle of poor communication dynamics between physicians and patients’ families, and wanted help from ethicists.
• The moral experience of caring for patients and interacting with clinical colleagues was a common factor in requests for consults. “Our data helps show that even if not the source of moral distress, moral experience is still relevant,” says Finder. Typically, moral experience is seen as relevant only in the context of moral distress.
“This suggests that ethicists should pay greater attention to the scope and breadth of nurses’ moral experience in general — not just in the context of moral distress,” says Finder.
• Reasons for requesting ethics consultations do not always match up with what, in the end, nurses found most valuable regarding ethics consultation.
“Here, again, emphasis on moral experience is highlighted,” says Finder. This strongly suggests that ethics consultation is not simply about resolving conflicts. For those performing clinical ethics consultations, the study’s findings are a reminder to pay careful attention to the specific kinds of moral experiences nurses undergo.
“Do not assume that if a nurse calls due to a question about a patient’s code status, that all that needs to be addressed is code status,” says Finder. “There may well be much more underneath that request.”
When ICU nurses at Northwestern Memorial Hospital in Chicago call an ethics consult, it often is because of a feeling that care is nonbeneficial. “That is the number-one issue that is causing us distress. Sometimes it is not exactly an ethical issue, but sometimes it is,” says Leah N. Goldschmidt, MSN, RN, CNL, education coordinator of the medical ICU.
A recent case resulted in significant moral distress for the ICU nurses. The family of an elderly patient insisted he continue to be a full code, despite suffering multiple system organ failure, on a ventilator, and requiring life-saving medications. Since the patient could not speak for himself, the clinical team did not have the opportunity to ask him what he wanted.
“It was hard for us to believe the patient would want to be intubated and attached to IVs, and at the final moments of his life to have CPR performed,” says Goldschmidt.
The entire clinical team, including physicians, were distressed over the case. “But what is different for nursing is that we are the ones who are at the bedside 12 hours a day,” says Goldschmidt. Ethical principles of nonmaleficence and beneficence came into play. “We feel we are causing harm to the patient when we are turning them and cleaning them and essentially prolonging their death,” says Goldschmidt.
Nurses requested an ethics consult. Still, the family continued to insist they were doing what the patient would have wanted, and CPR was ultimately performed. “From our standpoint, it was not a good outcome,” says Goldschmidt.
A debriefing was held after the case, led by the palliative care team. Ethicists took the opportunity to encourage nurses to continue to voice their concerns. “I tell my new nurses if they feel something is wrong to speak up — they’re not alone,” says Goldschmidt.
1. Bartlett VL, Finder SG. Lessons learned from nurses’ requests for ethics consultation: Why did they call and what did they value? Nurs Ethics 2018; 25(5):601-617.
• Stuart G. Finder, PhD, Director, Center for Healthcare Ethics, Cedars-Sinai Medical Center, Los Angeles. Phone: (310) 423-9636. Email: firstname.lastname@example.org.
• Leah N. Goldschmidt, MSN, RN, CNL, Education Coordinator, Medical Intensive Care Unit, Northwestern Memorial Hospital, Chicago. Phone: (312) 926-0443. Email: email@example.com.