A man admitted to the surgical intensive care unit (ICU) went into cardiac arrest, and was resuscitated. Afterward, he faced a complicated clinical course with intermittent decision-making capacity.

The clinical team responded to every new complication with additional interventions, but soon became concerned that continuing with this approach was not in the patient’s best interest. The patient’s wife disagreed, and demanded that full treatment, including CPR, be provided.

“This scenario ... is a classic case in the ICU setting,” says Cynda Hylton Rushton, PhD, RN, FAAN, professor of clinical ethics at Johns Hopkins Berman Institute of Bioethics. The case is described in a recent paper as an example of the kind of ethical dilemmas that clinicians face regularly.1 Rushton and an ICU colleague created a structured mapping process to approach ethical decision-making.

“Our aim was to surface some of the unconscious processes that get us stuck in a hurtful rut, and to identify a potential way forward,” Rushton reports.

For instance, nurses might view family members negatively because of an inability to accept the family member’s conclusions. Many nurses experienced moral distress when visitor restrictions were implemented during the pandemic.

“With hundreds of beds in hundreds of hospitals, all occupied by people enduring illness and injury alone, watched over by wary healthcare providers, considerable trauma is unfolding for all involved,” says Kathleen Turner, RN, CHPN, CCRN-CMC, the report’s co-author and clinical nurse in the medical-surgical ICU at the University of California, San Francisco Medical Center.

Critical care “sets clinicians, patients, and families on a high-stakes path,” according to Rushton. For healthcare providers, it is easy to allow habits or assumptions take over.

“For the clinician meeting what may feel like their millionth catastrophe, this individual patient’s situation can be superseded by an archetype — ‘We’ve seen this movie before,’” Rushton observes.

Patients and families are facing an unfamiliar, overwhelming situation. Some already expect disrespect from the healthcare system. “In emotionally charged and ethically complex situations, anytime we believe there is one right answer, and it’s the one we already know, that is the moment to pause and try this approach,” Rushton suggests.

The approach to which Ruston refers is the four “Rs”: Recognize what is behind problematic decision-making, Release preconceived attitudes, Reconsider new approaches, and Restart with a fresh focus. Turner says in the context of visitor restrictions, the approach could work something like this:

• Nurses can recognize their own anxiety caring for frightened patients who are not allowed visitors. “By becoming aware of my distress, I can take action to stabilize myself,” Turner says.

That makes it possible to consider the ethical principles at stake. Nurses vow to foster well-being, not to harm, and to deal with people equitably. The hospital has these same obligations to its staff and to the community. Patients’ families have a duty to care for their loved ones.

“From this vantage point, the actions of each participant make sense. It’s a shift from seeing myself as a bad nurse, my hospital as cruel, and my patients’ families as victims,” Turner offers.

• Nurses can release themselves from moral responsibility that is not theirs to carry. Nurses do not make the visiting policy, Turner notes. The hospital must adhere to public health guidelines.

• Nurses can reconsider focusing on things beyond their control. Instead, nurses look for ways to provide the most ethical care possible under less-than-ideal circumstances.

“There have always been individual family members who couldn’t be present at a patient’s bedside. We have found ways for them to tend their loved ones nonetheless,” Turner notes.

• Nurses can restart by forging new partnerships. Nurse committees, along with patient and family advisory councils, might partner with hospital leadership to determine how to return families to the bedside safely.

“Frontline clinicians, intimately familiar with workflows, hazards, and resources in their areas, can partner with leadership to promote physical and virtual family presence,” Turner suggests.

Ethicists should be present on the wards and in the ICUs, listening to the concerns of staff. “We recognize there may be considerable political and cultural resistance in some organizations,” Turner admits.

Clinicians or families may be up against hierarchies or other barriers. Ethicists might need to contact these individuals directly instead of waiting for a consult request. “[Contacting] staff models the stance organizations could be taking with at-risk communities,” Turner says.


  1. Rushton CH, Turner K. Suspending our agenda: Considering what will serve when confronting ethical challenges. AACN Adv Crit Care 2020;31:98-105.