Ethics in the NICU: A Nursing Perspective

Elizabeth Gingell Epstein, PhD, RN

Associate Professor of Nursing

UVA School of Nursing and Center for Biomedical Ethics and Humanities

meg4u@virginia.edu

Disclosure statement: I have nothing to disclose

Objectives

Identify 2 common ethical dilemmas encountered by nurses in the NICU.

Define the concept of moral distress and discuss 2 strategies to address the phenomenon.

Describe 2 benefits and challenges of a monthly collaborative complex case conference.

Ethical challenges we all see:

I. Frameworks for evaluating ethical dilemmasII. What nursing brings to the tableIII. Ethics consultation

Ethical challenges that are harder to see (but just as important):

IV. “Microethics”V. Systems problemsVI. Moral distressVII. Moral distress consultation/complex case discussion

Challenges for nursing in a changing environmentVIII.AccountabilityIX. Team collaborationX. But not courage

Ethical challenges we all see

Resuscitation in the DR Limits of viability Acceptability of offering ECMO, dialysis,

transplant Limits of parental authority

www.neonatology.org/tour/sociology.html

A different framework for evaluating ethical dilemmas

Principles Relationship-based reasoning

Beauchamp & Childress (2009); Gilligan (1987)

What nurses bring to the table

• 24/7 vigilance• The long-term view• Different types of knowing• A view from the middle• A sense for the subtle• Preventive approach

Anspach (1993) Epstein (2012) Frick (2003)

Ethical challenges that are harder to see: Microethics: A closer view Truog (2015)

Systems issues: Repetition, Routinization, Silos

Chambliss (1996); Shannon (1997); Maxfield et al. (2005)

Moral distress

“The experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards.” -Varcoe et al, 2012

“The judgment that one is not able, to differing degrees, to act on one’s moral knowledge about what one ought to do.” -Thomas & McCullough, 2015

www.besthealthcarerates.com

“Attending…coding a baby with a pulmonary hemorrhage and the endotracheal tube filled with blood, oscillating with chest compressions, and I was thinking, ‘This is wrong. This is so wrong.’”

--NICU Resident

Epstein (2008)

Common root causes

Hamric, Borchers & Epstein (2012)

Providing unnecessary/futile treatment

Prolonging the dying process through aggressive treatment

Inadequate informed consent

Working with colleagues who are not as competent as care requires

Lack of consensus re: treatment plan

Lack of continuity of care

Inappropriate use of resources

Providing care that is not in the best interest of the patient

Providing inadequate pain relief

Providing false hope

Lack of truth-telling

Disregard for patient wishes

External constraints

Inadequate communication among team members

Differing inter- or intra-professional perspectives

Inadequate staffing

Lack of administrative support

Tolerance of disruptive, intimidating, or abusive behavior

Pressure to reduce costs or pressure from insurance companies

Hierarchies within the healthcare system

Lack of involvement of team members in decision making

Policies or priorities that conflict with care needs

Fear of litigation

Hamric, Borchers & Epstein (2012)

Intent to leave

“I quit nursing last month for exactly this reason. The stress on caring nurses (and doctors) is unbearable. Competent nurses feel frustrated at their own powerlessness, frightened of being sued, and heart-broken about what is being done to patients for all the wrong reasons. Furthermore, the healthcare crisis is so severe that all excellent practitioners worry constantly about mistakes that occur every day simply because of the chaos in the system itself, not because anyone did anything incompetent…I came to nursing because I care so deeply about patients, but I left it because I want work that doesn’t hurt me as a person.”

--Response to P. Chen’s (2009) “When nurses and doctors can’t do the right thing.”

Moral Distress Consultation & Complex Case Discussion

Recognizing moral distress as legitimate

Avenues to address:Within unitWithin organizationFocus on coping/resilienceFocus on action

Complex Case Discussion

Arose from moral distress consultation

Ethical and morally distressing issues

Monthly multidisciplinary team meetings

Neutrality, elephants on the tableHamric, Borchers & Epstein (2012)

Challenges for nurses

Accountability

Responsibility

Team collaboration

But not courage

Thank you

References

Anspach (1993). Deciding who lives. Los Angeles: University of California Press.

Beauchamp & Childress (2009). Principles of biomedical ethics. New York, NY: Oxford University Press

Chambliss (1996). Beyond caring: Hospitals, nurses, and the social organization of ethics. Chicago: University of Chicago Press

Chen (2009). When doctors and nurses can’t do the right thing. NY Times

Epstein (2008). End-of-life experiences of nurses and physicians in the newborn intensive care unit. J Perinatol 28: 771-778.

Epstein & Hamric (2009). Moral distress, moral residue, and the crescendo effect. J Clin Ethics 20(4): 330-342.

Epstein (2012). Preventive ethics in the ICU. AACN Advanced Critical Care 23(2):217-224.

Frick (2003). Medical futility: Predicting outcome of intensive care unit patients by nurses and doctors: A prospective comparative study. Crit Care Med 31:456-461.

ReferencesGilligan (1987). Moral orientation and moral development. In Kittay & Meyers Women and Moral Theory. Savage, MD: Rowman & Littlefield

Hamric, Arras, Mohrmann (2015). Must we be courageous? Hastings Center Report 45(3): 33-40.

Hamric, Borchers, Epstein (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research 3(2):1-9

Maxfield et al. (2005). Silence kills: The seven crucial conversations for healthcare. Provo, Utah: VitalSmarts.

Shannon (1997). The roots of interdisciplinary conflict around ethical issues. Crit Care Nursing Clinics 9(1): 13-28.

Thomas & McCullough (2015). A philosophical taxonomy of ethically significant moral distress. J Med Philos 40:102-120.

Truog et al. (2015). Microethics: The ethics of everyday clinical practice. Hastings Center Report, 45(1): 11-17.

Varco et al. (2012). Moral distress: Tensions as springboards for action. HEC Forum 24:51-62.

Photos from www.morguefile.com