ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES IN CLINICAL PRACTICE

ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES IN CLINICAL PRACTICE

MEDICAL ETHICS 0749-0704/96 $0.00 + .20 ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES IN CLINICAL PRACTICE Walking the Line M. Catherine Hough, R...

628KB Sizes 1 Downloads 122 Views

MEDICAL ETHICS

0749-0704/96 $0.00

+

.20

ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES IN CLINICAL PRACTICE Walking the Line M. Catherine Hough, RN, MS, PhD(c)

Recent research has shown that health care professionals frequently are faced with ethical dilemmas in their clinical practice. These dilemmas may involve considerations such as allocating available resources, honoring the patient rights of self-determination or termination of life support, and allowing the natural process of dying to occur. Decision making has been complicated by practices that have evolved as a result of advanced technology. These practices have contributed to the artificial preservation of life and increasing health care expenditures. Less than a decade ago, the cost of health care figured only minimally into decisions made by the vast majority of health care professionals. The common practice was that if a health professional believed a patient might benefit, even minimally, from any procedure or treatment, then it should be provided. The decade of the 1990s has ushered in the era of justification and allocation of the use of health resources. These issues are exacerbated by ethical principles such as autonomy (the respect of self-determination), beneficence (the duty to do good), nonmaleficence (the duty to do no harm), and justice (the fair or just distribution of benefits and risks). Balancing the needs of society generates perplexities that health care professionals struggle with across the country.

From the Department of Educational Foundations and Policy Studies, College of Education, Florida State University, Tallahassee; and Baptist/St. Vincent’s Health System, Jacksonville, Florida

CRITICAL CARE CLINICS VOLUME 12 NUMBER 1 JANUARY 1996

123

124

HOUGH

Increasingly, society is beginning to realize that it is not only health care professionals who are faced with health-related ethical issues. Consumers of health care are demanding inclusion in the decision-making process of identifying and resolving these issues. Likewise, many health care professionals believe that ethical decision making is no longer the sole responsibility of physicians and that they also have a clear duty to be involved actively in the decision-making process. This belief is supported by recent mandates from the Joint Commission of Health Care Organizations (JCAHO), which states that institutions will have functioning processes in the form of ethics committees, ethics consultation, or the use of formal ethics forums such as ethics rounds that address ethical issues in a collaborative manner.Is The purpose of this article is to discuss the examples of specific ethical dilemmas faced by critical care nurses in clinical practice.'* These are presented in the context of critical theory/perspective transformation, specifically as these relate to experiencing as a means of learning and hanging.^, 4, 9, lo These theoretic perspectives are applicable to all adult learning but are interpreted through the unique experiences of the critical care nurse. The factor of the predominantly female nature of the nursing profession and its effect on experiential learning and perspective transformation is addressed?, l5 These learning paradigms and essential ethical theories are illustrated by specific cases that demonstrate the moral and emotional conflicts that critical care nurses experience in their daily clinical practice. A basic understanding of moral development theories that the moral agent will use to identify and to resolve ethical issues is critical. The following paragraphs present a brief overview of the dominant theoretic perspectives or paradigms, most commonly used with moral reasoning by members of Western society. MORAL DEVELOPMENT THEORIES

Ethics is a branch of philosophic inquiry that focuses on questions of a moral nature. UustalZodescribes ethics as The study of values in human conduct or the study of right conduct. It is a branch of philosophy, also called moral philosophy. Ethics is an attempt to state and evaluate principles by which ethical dilemmas can be resolved. Ethics offers a critical, rational, defensible, systematic, and intellectual approach to determining what is right or best in a difficult situation. (p 150)

Whereas moral conduct has been discussed for centuries by philosophers and theologians, any systematic approach to biomedical ethics is *Case studies are taken from a dissertation research study in process, and are protected by a Federal Certificate of Confidentiality issued by the US Department of Health, November 1993 (Hough, 1995).

ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES

125

a recent phenomenon? Biomedical ethics is a form of ethics that takes and applies theories and principles to issues within the context of health care delivery.

Moral Development of Professionals: The Nurse

In the area of adult moral development, there are currently two schools of thought that guide individuals as they engage in the process of ethical decision making. The first is found in the writings and research of Lawrence Kohlberg, who has devised a hierarchical scale to measure moral maturity.12,l3 Within this scale are levels at which individuals function according to their degree of moral development. A major criticism of Kohlberg’s work is that his research focused exclusively on young to middle-aged American men and the ethical principle of justice. Another criticism is that this theory ignores social experiences and the more emotional aspects of experiences-empathy, compassion, and feelings.8,l9 It is because of this criticism that recent research has questioned the appropriateness of using Kohlberg’s theory of justice ethics when determining the moral development levels of nurses. Measurement of a nurse’s moral development levels should be based on a theory that values caring and the more emotional aspects of experience.” 8*17, Another viewpoint, offered by Carol Gilligan; argues that women should not be judged by male perceptions, beliefs, or values. Gilligan looks at moral development from the feminine perspective and develops a care theory. This approach to moral decision making argues that it is necessary to develop a conceptual model of care. Within these two frameworks is the belief that with Kohlberg’s theory of justice ethics the decision-maker searches for agreement. With Gilligan’s care ethics, however, the search is for understanding. Recent qualitative nursing research has focused on moral reasoning and behavior among critical care nurses. Through narratives, authors attempt to demonstrate critical care nurses’ moral struggles within two moral frameworks: principle-oriented ethics (traditional, normative approach), and the ethics of care when working in critical care nursing According to Benner? ethics of care are dependent on the nurse recognizing salient ethical comportment within the context of specific situations found within professional practices and habit. Cooper6and Benner2 propose that although Gilligan’s care ethic may be more appropriate with a nurse’s general world-view, perhaps the more dominant approach to actual ethical decision making is found with principle ethics. This would support the contention that nurses often find themselves in situations of ethical conflict as they search for understanding of and agreement about perceived ethical dilemmas.*,5, For the remainder of this article, specific examples of ethical dilemmas are presented in a case-study format. These cases illustrate the struggle of critical care

126

HOUGH

nurses as they attempt to identify and to resolve ethical dilemmas in their clinical practice. NARRATIVES OF ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES

Four case studies are provided, covering a variety of ethical issues. The first two narratives focus on the ethical doctrine of double effects and the ethical principles of beneficence, nonmaleficence, and autonomy. A brief description of double effects is followed by two case studies in which critical care nurses are faced with the ethical dilemma of whether to medicate the terminally ill patient for pain even though the end result may be a premature death. The third case study addresses death recognition by critical care nurses who may recognize that the point has been reached for caring and acceptance instead of the technologic imperative driving their physician colleagues. Ethical principles in conflict in this case are beneficence, nonmaleficence, and justice. The final case study explores the ethical principle of veracity (truth-telling) when witnessing questionable or unethical behavior by other health care professionals. It also details the issue of disproportionate power found between the nursing and medicine professions. Ethical principles that are applicable to the final case study are autonomy, beneficence, and nonmaleficence. Sharing the Experience of Death: The Doctrine of Double Effects

The doctrine of double effects states that as moral agents we may not produce evils intentionally. It is ethically permissible, however, to do what may produce an evil or undesirable result if the intent was to produce an overall good effect and not the evil one.' Case 1: Double Effects

This case involves an intensive care unit (ICU) nurse who was faced with a decision of whether to medicate a terminally ill patient who was compromised hemodynamically and in extreme pain. The patient was a 52-year-old white man who was admitted earlier that day with an acute anterior-septa1 myocardial infarction (MI) in cardiogenic shock. He had a history of severe coronary artery disease and had suffered several MIS over the past 3 years. The patient, his family, and his physician all agreed that if he should have a cardiopulmonary arrest he would not be resuscitated. When the ICU nurse assessed this patient, he was cold and clammy with a blood pressure of 72/40, and his heart rate was 160. The patient was alert mentally and requested that the nurse give him something for the severe chest pain. The nurse recalled thinking that she needed to medicate this patient and that there was a high probability that he would die

ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES

127

when she administered the narcotic. After weighing the pros and the cons, the nurse decided to give the medication. The initial response to the medication was a further drop in blood pressure to 50/30 but it returned to the premedication levels within 10 minutes. The patient died approximately 4 hours after receiving the medication. During that 4 hours he was free of pain.

In this case the ICU nurse spoke of steps that she took to assist her in the process of deciding whether to medicate this individual and possibly have the medication prematurely shorten his life. The following is a verbatim passage taken from the interview: I was placed in a situation where I had to make a decision. I had to weigh the possible ramifications that decision was going to have. Would I let this man continue to be in excruciating pain, having his life extended maybe 3 or 4 more hours and him die, and having that family remember his pain for the rest of their lives, or to honor his wishes and give him the medications that was [sic] ordered with the chance that it might prematurely end his life? I can remember when I finally made the decision to medicate him was when I was able to rationalize to myself that I wouldn’t be giving him the medication to end his life, but I would be giving him the pain medication to end the pain.

This nurse’s situation is clearly a case of double effect. Although the unintended effect of medicating the patient would be a premature death (if only by hours), the intent of giving the narcotic was clearly to relieve his severe chest pain. The nurse began a period of internal ethical discourse and identified and evaluated what ramifications her decision to medicate or not to medicate would have. Although this patient died several hours later, the nurse believed that medicating him had a positive outcome. This is indicated by her statement that T. lived for probably 4 more hours, but the last 4 hours he was painfree. His family was in and out ...they reminisced about the past, about baseball games and family times. They had good memories, not memories of pain and suffering.

A second example of double effects is seen in the following case study that also addresses the issue of medicating the terminally ill patient. Case 2: Double Effects This scenario involves a middle-aged man who was in an automobile accident. He had sustained numerous internal injuries and was on life support for several months. He required multiple intravenous vasoactive infusions over this extended period to maintain perfusion. As this individual’s condition progressively worsened, the ICU nurse stated, “By looking at him, I could tell he was in considerable pa in...I knew in my heart that if I gave him pain medicine that it probably would be the last medicine I ever gave him.” The decision was made that medically, there were no more treatments that would benefit this individual. This nurse spoke of discussing this case with

128

HOUGH

fellow nursing colleagues. She felt that they were very supportive of giving him the medications. She spoke of waking up a medical resident who she had worked closely with on this case. The following is an excerpt from her interview: "I woke him up and said, 'Listen, I need to talk to you about this.' He came over and he asked, 'What do you want from me?' I said, 'I need to hear you tell me what you would do.' He said, 'No, I can only tell you I would pray about it.' I said I did pray about it, so he said, 'Pray again and listen harder, you're a good nurse and you make good choices.' I needed to hear that and so I cried. I walked over to the bed and I had the pain medication. I still believe that I did what needed to be done even though I knew the risk would be that he would quit breathing; I didn't know that for a fact but I knew that was a likelihood, but I medicated his pain because he was in pain and that was the only thing I could do for him at that point in time. I tried to listen when I prayed as to what my choices were...it still makes me feel like-did I play God a little bit? I don't believe so; I believe in my heart that I tried to listen to what God told me. His wife stayed with him in the room and he died about 15 minutes later."

The preceding case is also a n example of double effects. These two cases illustrate the moral struggle that critical care nurses experience when deciding to hold or to administer pain medication. Just a s important, they illustrate the emotional struggle once the decision is made. Recognizing Death Before the Doctor: Death Recognition Critical care practitioners work in a dynamic, high-technology, a n d sometimes chaotic environment. Often the technologic imperative a n d fear of death (often viewed a s professional failure by the health care provider) obscure when the appropriate time has been reached for caring and acceptance. The following case involves a 20-year-old woman who was transferred from a small community hospital to a large medical center in critical condition. Case 3: Death Recognition

When asked to describe the most difficult ethical dilemma faced in her clinical practice this critical care nurse responded, "Keeping A. alive! It makes me cry. She was 20 years old, she had just had a baby, she had cardiomyopathy. When she came to our hospital her ejection fraction was not compatible with life. A cardiac transplant was needed...so we just kept coming and coming. I was part of what is basically the torture of a human being for 11 weeks...at the end she was ventilator-dependent and no longer conscious, she was all swollen, all of her skin would come off, it would come off in your hands. She didn't look like a person any more. We just kept coming, on and on and on. In the end, it wasn't until we requested a meeting with everyone who was dealing with A. and I remember there were seven physicians and all the nurses were in a turmoil because it was so very difficult to go in there every day and take care of this person as she literally fell apart. All these doctors would just sit there with their body systems: 'I'm the heart, I'm the lungs, I'm the liver,' and we all

ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES

129

sat there. About five or six nurses got up and spoke their piece. I was one, it was the first time that they became aware of the anguish that they'd cause. It was kind of interesting to watch their faces when they finally realized what they were doing to this human being. After the meeting they stopped. It has been so many years but to this day it hurts me that I was a part of this."

The critical care nurse's realization that future medical treatment would be futile led to a collective shift in the perspective of the nursing staff members. The request for the patient care conference to discuss the issue of medical futility led to their physician colleagues' acceptance that the appropriate time had been reached for acceptance of a terminal state and compassionate comfort care. Truth-telling: Blowing the Whistle Case 4: Blowing the Whistle

A 76-year-old white woman presented in the emergency room. She was hypertensive, clammy, complaining of severe lower back pain. The chest radiograph showed a thoracic aortic aneurysm. An emergency laparotomy for a supposed abdominal aortic aneurysm was done. The family was told that the pancreas was inflamed; however, the amylase and the lipase were within normal limits. Postoperatively, the surgeon instructed the nurse to wean her from the ventilator and transfer her out of the unit. The patient was extubated and visited with her family for a period and then the family went home. Over the next 20 minutes the patient became very restless and agitated and proceeded to cardiopulmonary arrest. Cardiopulmonary resuscitation was attempted but was unsuccessful.

The following excerpt is taken from the actual interview with the critical care nurse who describes the preceding case: She went into EMD and we couldn't get her out of it. We did the entire resuscitation talking to the physician over the telephone. She died before he ever got there. In the meantime I had to call her family back in. She was already dead. I took them back out into the waiting room and the surgeon got there before I had to tell them that she was dead. The husband was just beside himself. He said, "Why did she die? I thought she was doing better," and the surgeon then told them she died of complications of pancreatitis. I had the lab work that said there was no pancreatitis. The surgeon told them that complications of pancreatitis can make you have breathing problems, and stopping breathing was the first thing that had happened to her. He then told them if they weren't content with the quality of care he would be happy to open her up, take all her body organs out, cut them up piece by piece, put them under a microscope and try to determine another cause...how cold, how cold. I don't believe he wanted them to know the cause. I believe the patient died of a dissecting thoracic aneurysm. He flat lied to them in front of my face. I started to say we could do an autopsy only on her chest, but he put his hand up and said, "I'll handle this," and then told

130

HOUGH

me later in lieu of the situation he felt he had to take a controlling hand. I was still in a state of shock. I never confronted the surgeon about this ....

Although health professionals are aware of their professional obligations, they seldom report a member of another profession or a colleague. When asked why she never confronted the physician in the preceding situation, she responded, ”You know, there is a real male/female domination that goes on between the nursing and medical professions which is becoming more and more unpalatable to me.” One nurse describes the issue of disproportionate power in terms of personal risk in the following passage: I don’t know why nothing ever gets said. You‘re afraid. They have a lot of control. Whistle blowers pay a price, and [the situation] has to be so blatant that it gets past the point of your ethical sensitivity that it is really something that cannot continue. One time I refused and would not follow orders. I called the supervisor and said I refuse. This person is doing something that will be harmful to the patient, and it was, and it killed him. But I told the supervisor I wouldn‘t take responsibility for it ...I filed, you know how you do those write-up things. I wrote him up because I wanted it real clear that I knew this would cause harm and there was no way I was going to do it.

The “traumatic se~erity’’’~ of the above was so intense that the critical care nurse experienced a transformation of sort in that no other option was left except to ”blow the whistle.” When asked with what frequency nurses in this particular setting responded in this manner, she said It depends on what they feel the support will be. If they watched someone else do this and if it just comes back in your face and you’re told the doctor is always right you tend not to do it again ...you have to pay a price. And that price may be that you are not allowed to rise at the institution. If I feel it’s wrong I’ve gone ahead and done it but it’s not always supported and there have been times when you received more support.

Another critical care nurse described this as feeling as if one is constantly “walking the line” with ethical decision making in clinical practice. The consensus of these nurses was that if critical care nurses feel that they are supported they will be more likely to report unethical issues. When one nurse was questioned as to where she saw nursing going in the future in this respect, she answered I am hoping that we will realize who and what we are. That we will acquire the power that goes with who and what we are which we don‘t have now. I hope that we will play an increasing role in the provision of compassionate, ethical care...we are primarily female and we have a different outlook on these matters and I think that our perspective is one that must be considered.

ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES

131

Many critical care nurses believe that they do play an important role in providing this care. The following is one example of such a belief. We have input in my unit. It’s not universal in my institution but in [the] MICU [medical intensive care unit], where I work, medicine is extremely sensitive to what nursing has to say.

One critical care nurse with 15 years of experience discussed the importance of experience in conjunction with physician support when she said Nothing is more frustrating than to put it all together, present it to the physician and have him devalue your assessment and hang-up. Nothing is more supportive that to have a physician who says, ’OK, I’m going to come in and look at it.’

ANALYSIS

The education that resulted from direct participation in the case studies in this article is referred to in the adult and continuing education literature as experiential learning7* This learning was related directly to experiencing the events described in the four case studies through direct participation. The importance of the role of experience in the case studies is best illustrated with how one of the nurses responded-”It’s that age-old thing again...how could I have understood this before I experienced the reality of working in critical care? I don’t think I could have.” Another nurse describes the importance of experiential learning when she said, “You can educate people and you can tell them about it, but until they experience it, they won’t know ...you have to have been out there in the trenches to know what reality is. It’s real that you are a major decision maker. It’s not real that the doctor is always right.” The emerging theory of perspective transformation can be used to describe how critical care nurses learn by making meaning out of their experiences. This reflective learning can change or transform one’s perspectives of meaning. The traumatic severity of the ethical dilemmas experienced were a major factor in determining the likelihood of a transformation. In case study four, this transformation is illustrated best as the critical care nurse spoke of “blowing the whistle.” Another critical care nurse expanded on experiencing such a shift in perspective when she said Since that patient died it was a big turning point where I ceased to back down from the physician. If that occurred today and I could not get appropriate physician response I would call the chief ...I would call the administrator on call, I would get action. You cross that line only once.

132

HOUGH

IMPLICATIONS The cases presented clearly show that it is more often than not the critical care nurse who is the one who is left to follow through with ethical decisions made by her- or himself or other members of the health care team. It is imperative that the voices of those who are expected to carry out these decisions be included in the ethical discourse process. With recent mandates from accrediting agencies, professional organizations, and state and federal statutes, nurses’ voices are being heard as they begin to serve on hospital ethics committees. Ethics committees, ethics rounds, and ethics consultations are excellent nontraditional educational forums for educating nurses and other health care providers. In regard to breaches in professional codes of ethics, health care institutions have the duty to provide some type of formal mechanism for handling such issues. Those institutions that lack such mechanisms need to work to establish them. Those institutions that have formal policies and procedures in place need to educate their employees about these policies and encourage all levels of staff to report suspected breaches. Future research is needed in several areas. One area should address individual perceptions of critical care nurses as they construct meaning and engage in ethical decision making within their clinical specialty. Another should be to continue to evaluate the importance of experience in making sound, systematic, rational, and defensible choices in ethical decision making. ACKNOWLEDGMENTS I would like to thank my professional colleagues and family members who have given their time to read various drafts of this article. Their insights have been invaluable. Perhaps most importantly, my thanks to the critical care nurses who have shared so willingly their powerful professional narratives that appear as case studies in this article.

References 1. Beauchamp TL, Childress J F Principles of Biomedical Ethics. New York, Oxford University Press, 1989 2. Benner P:The role of experience, narrative and community in skilled ethical comportment. ANS Adv Nurs Sci 871-21, 1991 3. Borzak L: Field Study: A Source Book for Experiential Learning. Beverly Hills, Sage Publications, 1981 4. Brookfield S: Adult Learners, Adult Education and the Community. New York, Teachers College, Columbia University, 1984

5. Cooper MC: Gilligan’s different voice: A perspective for nursing. J Prof Nurs 5:lO-16, 1989 6 . Cooper MC: Principle-oriented ethics and the ethics of care: A creative tension. ANS Adv Nurs Sci 14:22-31, 1991 7. Fall JM, Lynch JJ: Bioethical decision making for the health care professional. Nursing Connection 1:19-28, 1988 8. Gilligan C: In a Different Voice. Cambridge, MA, Harvard University Press, 1982

ETHICAL DILEMMAS FACED BY CRITICAL CARE NURSES

133

9. Houle C O Continuing Learning in the Professions. San Francisco, Jossey-Bass Publishers, 1980 10. Jarvinen A: Experiential learning and professional development. In Veil SW, McGill I (eds): Making Sense of Experiential Learning. Philadelphia, SRHE and Open University Press, 1989 11. Joint Commission on Health Care Organizations: JCAHO Standards: Section 1. Patient Rights and Organizational Ethics (standard RI.1.). JCAHO, 1994 12. Kohlberg L The Psychology of Moral Development. San Francisco, Harper & Row, 1984 13. Kohlberg L Stage and sequence: The cognitive development approach to socialization. In G o s h DA (ed): Handbook of Socialization Theory and Research. Chicago, Rand McNally, 1969 14. Mezirow J: Transformative Dimensions of Adult Learning. San Francisco, Jossey-Bass Publishers, 1991 15. Mezirow J, et al: Fostering Critical Reflection in Adulthood. San Francisco, Jossey-Bass Publishers, 1990 16. Munhall P: Moral reasoning levels of nursing students and faculty in a baccalaureate nursing program. Dissertation Abstracts International 40(9-B):421f+4217, 1980 17. Munhall P: Nursing philosophy and nursing research: In apportion or opposition? Nursing Research 176-181, 1982 18. Nokes: The relationship between moral reasoning, the relationship dimension of the social climate of the work environment, and perception of realistic moral behavior among registered professional nurses. Dissertation Abstracts International 46(4B):1119, 1992 19. Sherblom S, Shipps T, Sherblom J: Justice, care, and integrated concerns in the ethical decision making of nurses. Qua1 Health Res 3:442-464, 1993 20. Uustal DB: Nursing ethics: Values, ethics, and professional decision making. Innovations in Oncology Nursing 3:1,4,13-15, 1987

Address reprint requests to M. Catherine Hough, RN, MS, PhD(c) 7028 Delisle Drive Jacksonville, FL 32244