At a large, academic medical center, researchers recently overheard this concerning comment made by a critical care nurse: “Realistically accepting that nurses often have little control over ethical dilemmas in their practice is one way of coping with ethical conflict.”1
“We do not want nurses to become complacent or lose their motivation to advocate for patients and their families,” says Natalie S. McAndrew, PhD, RN, ACNS-BC, CCRN, the study’s lead author and an assistant professor in the College of Nursing at University of Wisconsin-Milwaukee. McAndrew and a colleague analyzed open-ended responses from a survey with ICU nurses, and identified three themes:
• ICU culture, practices, and organizational priorities affect patient suffering. Reluctance to talk about death and dying contributed to nurses’ distress. “That can delay important discussions with patients and their family members,” McAndrew says.
Nurses feel caught in the middle. They worry that decision-making is delayed. Team discussions with families on possible outcomes of the patient’s critical illness are not frequent enough. “We feel terrible for these families and want to allow them to continue to have hope. But then there’s this idea of false hope that can lead to delayed decision-making,” McAndrew notes.
In the eyes of nurses, this leads to prolonged patient suffering. Life-sustaining treatments may continue for prolonged periods without any clear benefit. “We have to take a step back and realize that every team member’s perspective is important,” McAndrew adds.
• During ethical ICU conflicts, nurses are marginalized. One nurse remarked, “Nurses are the ones constantly in the rooms, holding [the patient’s] hand and giving families the support they need. But doctors don’t understand how we feel.”
“Nurses are very inquisitive about ethical issues and want to be a part of that discussion,” McAndrew observes.
Informal discussions with ethicists can help. Formal ethics consults do not happen daily. “Chatting with ethics experts biweekly or using a process of monthly rounding could really help nurses process some of the things they have questions about,” McAndrew offers.
Nurses have asked questions such as: “I have a patient care situation, and I am not sure if there is an ethical conflict or not. Can you help me talk through this case?” “How do you, as an ethicist, conduct your assessment of a case when a formal ethics consult is called?” “What is your approach to addressing conflicts about goals of care?” “How do you think ICU teams can improve their communication with families about life-sustaining treatments?”
• Use organizational resources to alleviate ICU nurses’ moral distress. “There will always be ethical dilemmas in the ICU,” McAndrew says. Prognostic uncertainty plays a big role in this.
There are times when the clinical team has to wait to see how patients will respond to treatment before making a decision on whether to withdraw life-sustaining interventions. “That can be difficult for nurses who may provide care to a patient for an extended period,” McAndrew explains.
One nurse put it this way: “It seems that frequently we do so many interventions on patients when it will not change the outcome of the situation. I feel like more effort should be made to talk with families and patients about the quality of life, rather than quantity.”
Ethicists know how to help nurses raise these valid concerns. “We should be building relationships with ethicists and welcoming them into the ICU environment,” McAndrew suggests.
- McAndrew NS, Hardin JB. Giving nurses a voice during ethical conflict in the ICU. Nurs Ethics 2020; July 14;969733020934148. doi: 10.1177/0969733020934148. [Online ahead of print].