WHEN EXPERIENCING an ethical dilemma, nurses may believe they don't have enough time to consider options and seek resources.1 But in fact, many resources are usually available to facilitate clinical ethical decision-making. An ethics consultant can aid in ethical decision-making in today's complex healthcare environment.
Historically, healthcare institutions weren't required to have a formal ethics mechanism.2 Today, however, healthcare institutions utilize either an institutional ethics committee or an individual ethics consultant model as their identified ethics mechanism. Both mechanisms can provide ethics education, policy development, and case consultation, but the methods for providing ethical consultation may differ.3
Institutional ethics committees (IECs) may be comprised of a representative sample of healthcare professionals from the institution. Additional members may include a community representative and/or a person with specialized education in ethics or philosophy. Due to the size of the group, case consultation often occurs retrospectively at a routine meeting time. However, some IECs may convene a smaller group of members to provide real-time consultation at the bedside or offer the services of an individual ethics consultant to provide one-on-one, real-time assistance during an ethical dilemma. The consultant is usually a healthcare professional (nurse, physician, social worker, or chaplain) in the institution with specialized education in ethics and/or philosophy. One limitation of the individual ethics consultant model is that the ethical deliberation doesn't benefit from the group-think perspective that an IEC can provide.
Utilizing an ethics consultant
Institutional policy delineates how to initiate a request for an ethics consultation. Using the ISBAR format (identify, situation, background, assessment, recommendation) lets the nurse communicate directly about his or her concerns and need for immediate assistance.4
When the ethics consultant arrives on the unit, the consultant will begin gathering data about the patient and the current situation. This might include reading progress notes and reviewing any advance directive or clinician orders for life-sustaining treatment (COLST) included in the medical record. The consultant will also want to talk with the various stakeholders, including the patient's family, primary care provider, and nurse.
The consultant's involvement includes these elements:
* Promoting autonomy. Many ethical dilemmas are created by a communication failure.1 In the ISBAR example presented below, the patient's nurse, Anne, is struggling to effectively communicate Mrs. P's wishes to her family. (See Initiating an ethics consultation.) The consultant might ask the patient's brother, "Tell me how your sister has lived her life. Does she have values or beliefs that she's used to make decisions at other times in her life?"
Through this discussion, the consultant will attempt to enlighten the family and nurse about Mrs. P's preferences and allow Mrs. P's values to guide the decision-making about her treatment. By promoting Mrs. P's autonomy, the consultant will lessen the burden on the nurse and family.
* Supporting the nurse. The ethics consultant could support the nurse throughout and after this ethical dilemma by providing ethics education. Individuals often feel empowered when they can label the ethical issue being experienced. In this case, the consultant can help the nurse understand that this dilemma revolves around the doctrine of double effect, defined as "a single act having two foreseen effects, one good and one potentially harmful (such as respiratory depression)."5 The key to understanding double effect is understanding the intentions behind the act. In Mrs. P's situation, the intent of opioid administration is to make the patient comfortable. A potential unintended outcome would be respiratory depression, which could hasten death.
* Making a recommendation. Ethics consultants, like all healthcare consultants, provide recommendations on how to proceed. In this case, the consultant may conclude that, "based on Mrs. P's previous conversations about valuing comfort over longevity, I recommend that the medication be administered."
The American Nurses Association's Code of Ethics for Nurses with Interpretive Statements also provides guidance and support for the nurse's decision-making. "Nurses consider the needs and respect the values of each person...Respect for patient decisions does not require that the nurse agree with or support all patient choices."6
Moral courage is the ability to rise above fear and act based on your ethical beliefs.7 The nurse clearly described her fears related to potentially hastening Mrs. P's death. She can rise above her fears by recognizing the full scope of her nursing role and responsibilities, which includes a primary commitment to the patient and the patient's values. The ethics consultant should urge the nurse to reach out to colleagues, supervisors, and/or the ethics consultant if she notes a numbing of her moral sensitivity, a withdrawal from involvement in ethically challenging patient situations, or feelings of professional compassion fatigue.8,9 Listening to and validating the nurse's ethical experience are key actions to promote the nurse's resilence.8
Reach out for real-time assistance
Nurses continue to experience clinical ethical dilemmas involving questions related to end-of-life decision-making and the doctrine of double effect. An ethics consultant can provide real-time ethical assistance and encourage the nurse to act with moral courage to resolve ethical dilemmas in the future.
Initiating an ethics consultation
When initiating the request for a consultation, the nurse could follow a modified ISBAR communication strategy. For example:
Identify: Hi, this is Anne on the pulmonary-telemetry unit. I'm the nurse caring for Mrs. P.
Situation: Mrs. P is currently experiencing respiratory distress.
Background: Mrs. P is 92 with a long history of chronic obstructive pulmonary disease and a do-not-resuscitate (DNR) order with the goal of promoting comfort. Her brother is at the bedside and does not agree with the DNR order.
Assessment of ethical issue: Mrs. P has an order for a p.r.n. opioid for dyspnea, but her brother is concerned that by giving this medication I would be helping Mrs. P to die. I am not sure how to respond to Mrs. P's brother's concerns. And now, his worries have made me question the use of this opioid.
Recommendation: I'd like someone from the ethics consultation service to come to the pulmonary-telemetry unit now to help determine the best action to implement at this point in Mrs. P's care.
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