Often, healthcare providers and families are faced with the decision to provide aggressive care for dying patients with various disease processes. But these efforts to prolong life may place nurses in an ethical dilemma. As one researcher notes, "In the enthusiasm for technology and cure, often patients' wishes, quality of life, and consideration of the burden of treatment compared with the benefit are overlooked."1
In the adult critical care setting, many patients are unable to participate in the decision-making process; therefore, family members and physicians are the decision makers. Less than 5% of patients in intensive care are involved in the plan of care, and family members may be uninformed of the patients' preferences.2 Most deaths in the ICU occur after withholding or withdrawing life-sustaining treatment.1
Families are highly stressed as they strive to understand and cope with the physical, financial, social, and psychological demands of their loved one's illness but are requested to make a plan of care decision during this time.3 The decision maker may be holding onto hope, and may also be in conflict of knowing what the patient wants and what the other family members want done.3
Research findings show that no attending physician believes that death was prolonged for any of his or her patients; this supports the hypothesis tha attending physicians believe that the patient received the most appropriate care.4,5
Nurses experience ethical distress when treatment is ordered that they perceive as prolonging death and causing suffering unnecessarily.4 The lack of collaboration and input from nurses during the end-of-life discussions between families and physicians may affect nurses' perceptions of prolonging the dying process. One study showed that 40% of nurses believed they'd acted against their conscience during some point of caring for patients at end of life.1
Nurses must be included in the decision-making process for withdrawal of care. Studies have shown that the need for withdrawal of life support to prevent prolonging the dying process is recognized by nurses before physicians.5 Educational preparation and clinical experiences haven't prepared nurses well for end-of-life care.1 Processes must be in place to allow a forum for information sharing among the healthcare team.
Nurse managers can help reduce perceived ethical dilemmas and moral distress by helping nurses voice their concerns in a nonthreatening, nonjudgmental environment. By incorporating ethical discussions into daily multidisciplinary rounds, nurse managers provide an opportunity for healthcare providers to communicate ethical concerns and to solve problems by addressing those concerns. Using the DECIDE model can ensure that ethical concerns are addressed.
Ethical theory and model
Biomedical ethics is based on four principles: respect for autonomy, nonmalfeasance, beneficence, and justice. Life-sustaining treatments should be used for the benefits that can be provided for the patient and justified by the benefits outweighing the potential harm. To be ethical, the goals of care for any individual patient and the family must be determined based on the potential to provide more good than the potential for doing harm.6
DECIDE is an acronym for define problems, ethical review, consider options, investigate ethical outcomes, decide on a plan, and evaluate results.7 The DECIDE model provides an ethical approach to problem solving with clear objectives. Moving through the steps helps to clearly identify the options for the appropriate plan of action and evaluation of the outcomes. See The DECIDE model in action for an illustration of how the model can be used to address nurses' ethical distress during aggressive care during end-of-life situations in an ICU. Involved physicians have a good rapport with nursing staff and communicate daily with other caregivers during multidisciplinary rounds.
Define problems: Nurses need to explore the conflict they're experiencing to determine whether all pertinent facts have been obtained. A physician note saying a discussion regarding end-of-life issues with the family has occurred may not adequately describe the decision-making process. The nurse may not understand the resulting plan of care. Nurses witness the patient suffering with the treatment prescribed, yet the probability of a positive outcome is low. Nurses should explore the conflicts so that their sense of moral accountability isn't ignored or diminished.6
Ethical review: Nurses experience moral distress when they perceive that the wrong course of action is being pursued, and that the prescribed treatment is contributing to the patient's suffering. A conflict has occurred between nonmalfeasance and beneficence.
Consider options: Two options are available to nurses: remain silent when witnessing perceived wrong decisions or voice perception of patient's suffering and nurses' distress. The first option doesn't help reduce or eliminate the distress that nurses are experiencing; in fact, remaining silent only compounds the distress. As a result, nurses may change positions or leave the profession.8 A better option is for nurses to talk to the healthcare team about their perception of the patient's suffering and the distress the nurse is experiencing. Opening the channels of communication may lead to a change in the plan of care. Daily multidisciplinary rounds provide a setting in which all healthcare workers have the opportunity to present their perceptions. Ethical considerations could be discussed at this time to support and enhance collaboration and multidisciplinary ethical decision making.4
Investigate ethical outcomes: Given the options of remaining silent or speaking up, the ethical thing to do would be to speak up. Nurses can present a realistic picture and speak for the patient.9 Nurses speaking on ethical issues during multidisciplinary rounds will have input on decision making for the plan of care.
Decide on a plan: By asking one question during rounds—"Does anyone have any ethical concerns with this patient's care?"—the management team opens channels of communication. Before a patient's condition deteriorates, many nurses correctly anticipate crises.9 Even if no other healthcare team member has objections, the nurse has an opportunity to answer the question and be heard.
Evaluate results: During multidisciplinary rounds, was the question asked for every patient? Was the healthcare team open to individual perceptions? Was the plan of care altered, or were individual perceptions clarified or changed? Was an ethical conference set when agreement couldn't be reached? Leaders must provide an environment where ethics is valued and nurses' distress is understood and attended to in a supportive manner.9
Inclusion is key
Nurses often experience distress related to ethical decisions made for patients. Part of the dilemma relates to being excluded from end- of-life decisions. Another part of the dilemma is the lack of communication of why such decisions are made. The nurse is then supposed to take care of the patient based on previous decisions without having a forum to verbalize discontent on the plan of care. Further studies are needed to overcome this issue and to look into causes and possible mechanisms of change to alleviate nurses' distress.
Consider asking, "Does anyone have any ethical concerns with this patient's care?" to open dialogue during rounding. For example, during patient rounds at the bedside, which may include the patient's nurse, unit manager, unit intensivist, social worker, case manager, chaplain, and a respiratory therapist, the nurse manager would ask about ethical concerns. This gives healthcare provider feedback on the plan of care and lets members of the healthcare team verbalize concerns and receive clarification. If disagreement remains on the ordered plan of care, nurses could then refer the issue to the appropriate ethical bodies within the organization.
Using the DECIDE model may decrease nurses' distress by letting them clarify misperceptions or advocate for changes in care plans. As one expert states, "It is in dialogue that medical ethics has its finest hour and that the practical wisdom of clinical practitioners moves from ethical shibboleths to more refined moral reasoning and sensibilities."10
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