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Creating an Ethical Environment Where Courage Can Flourish Kate Payne, RN, JD Director of Ethics and Palliative Care Saint Thomas Hospital.

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Presentation on theme: "Creating an Ethical Environment Where Courage Can Flourish Kate Payne, RN, JD Director of Ethics and Palliative Care Saint Thomas Hospital."— Presentation transcript:

1 Creating an Ethical Environment Where Courage Can Flourish Kate Payne, RN, JD Director of Ethics and Palliative Care Saint Thomas Hospital Nashville, TN 37205

2 Objectives Define and describe moral distress Identify contributing factors and causes Identify strategies to address moral distress and develop moral courage Describe why it matters

3 About the Law Protect Ethics/Reduce Liability – Identify and clarify the dilemma – Demonstrate good judgment – Communicate effectively – Facilitate negotiation – Improve decision-making Ethics is the ceiling, law is the floor


5 Ethics: Why? Decision making guided by ethical decision making processes Decision making informed by ethical values Decrease moral distress

6 What is Ethics? It can be about resolving dilemmas. It can be about individual actions. It is also about what kind of persons we are becoming, our character and how our choices shape us. Ethics is ultimately about human flourishing, about living well, about achieving good through means that are consistent with real human values and needs.

7 What is Organizational Ethics? It can be about compliance. It can be about due diligence. It can be about resolving value conflicts. Organizational ethics is about. – Integrity – Decisions/actions that are consistent with moral identity and values of the organization – Helping the organization, its associates, and the communities it serves truly flourish

8 Role of Ethics Mechanisms Improve and enhance the quality of patient care – Care of employees Education – Committee, staff, community Administrative – Policy development and review. – Oversight and comment on operations with ethical impact Consultation and case review – Conflict resolution Inform other institutional efforts – Regulatory compliance – Reduction of costs (without increasing mortality)

9 Ethics Experience Elemental work: protect……..from harm Social safeguard for potential harm Examine differences Recognize that conflicts are more Awareness of values in play, conflicts of interest Proper place of ethical theories Ethics is a group activity Unique decisions about individuals in relationship(s)

10 Principled Decision Making adapted from Robert Orr, MD FAITH BASED Sanctity of life Compassion Service Meritorious suffering Redemptive suffering Contentment Mercy Grace Hope Scripture Eternity Ritual Social justice Respect for life Truth telling Non-exploitation Advocacy Benefit/burden Free will Obedience Stewardship Faith Sovereignty Dominion Gods purpose Diagnosis Prognosis Treatment options Values Goals Wishes Social Cultural Legal Financial Physical Psychological Social Spiritual Patient Preferences Contextual Features Medical Indications Quality of Life SECULAR Non-Maleficence Beneficence Justice Respect for Autonomy Fidelity

11 Model Professionals Obligation Nature of Relationship Nature of Health Care Beneficent Preventive Covenant Contractual Business Commodity Service Obligation Life-style Negotiated good Buyer/Seller Sacred trust Unilateral option Trust (fiduciary bond) Contracting equals Commitment, Skill Commitment to life N/A Act for good of patient Supply specific service Health Care Models

12 Why Ethics? Need a moral compass to guide difficult decisions that have to be made in the health care context. N S WE

13 Moral Compass Mission Values Ethics Vision

14 Defining and achieving a desired future Best hindsight and foresight for action Possibilities The best healthcare system Your best life Fat free chocolate

15 Mission Mission makes us who we are – It is our purpose Human beings are valuable – Because they are created by God – People are ends unto themselves Excellent practice, excellent care – Is where mission finds form and expression

16 Values What is most important Priorities Worth Value set – Personal values – Professional values – Organizational values

17 Virtues/Values Cardinal virtues – Prudence, courage, temperance and justice Modern virtues – Unconditional positive regard, charity, compassion, trustworthiness, vigilance and agility Other – Dedication, loyalty, honesty, creativity, faith, family, care of the poor, competence, learning

18 Ethics Act in accordance with values based on universal principles External reflection of an internal moral code Actions that enhance the well being of others

19 So much for moral clarity.

20 Ethical Dilemmas Conflict between two rights Principles, decision making frameworks, or tools help clarify what is important Ethics process – ID areas of conflict – ID (other) resources – Provide support, understanding – Help move toward resolution Goal/hope: a 3rd way forward – Something besides two extremes

21 Ethical Components of Moral Distress Obligations of self Obligations of others Boundaries Risks and benefits of action Critical thinking/response – Knowledge, skills, resources needed – Anticipation – Management – Action

22 Care Giving: A Moral Endeavor Roots of the caring professions Promotion of ideal for patient care – Respect for persons – Conduct by advocacy – Safe and best care Care giver role/relationship – Fundamentally ethical – Care giver role/relationship is complex Patient/client focused caring Some distress is unavoidable

23 Painful feelings and/or the psychological disequilibrium that occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. – Jameton A. Nursing Practice: The Ethical Issues. NJ:Prentiss-Hall. 1984 Moral Distress Defined…

24 …defined 1993 Jameton distinguished: – Initial: frustration, anger and anxiety due to Institutional obstacles Interpersonal conflict about values – Reactive: due to failure to address initial distress 2000 Webster and Baylis included – Failure to pursue right course of action due to Error in judgment Personal failing Circumstances beyond control – May feel cherished beliefs violated Compromised integrity

25 ..the pain or anguish affecting the mind, body or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; yet as a result of real or perceived constraints, participates in perceived moral wrongdoing. – Alvita Nathaniel MSN, RNCS In Nursing World, July 28, 2002 ….defined

26 Other/Related Distress… Jading – A process leading to exhaustion from being overdriven to perform long, continued labor and/or severe or tedious tasks. Burn out – Individual or group stress related to ones relationship with the work environment Grief out – Repeated, sustained and often unresolved grief and loss

27 …distress Compassion fatigue – Gradual lessening, over time of ability to be compassionate. – The price one pays for caring. – Emotional stress experienced from exposure to the suffering of others. Secondary Traumatic Stress (STS) – Presence of Post-Traumatic Stress Disorder (PTSD) in the caregiver. Both STS and CF are caused by exposure to patients who have been traumatized or are suffering, not to the traumatic event itself. – Vicarious traumatization


29 Personal Psychological/emotional Closeness/identification with patient/client Boundaries Isolation Feelings of powerlessness or helplessness Compromise of ones standards of care Feelings of failure or guilt – Inability to talk about it Grief and loss – Lack of time to process – Accumulated grief and loss – Lack of closure Sustained proximity contributes to sense of responsibility

30 Professional Barriers Staffing – So low, care is inadequate – Lack of time, skill – Novice staff – Multiple deaths in close succession – High patient/client acuity Organizational change – Quality, safety – Cost cutting: Doing more with less Leadership dynamics Nature of relationships – Closeness/Identification – Patient and/or family issues Effectiveness of team – Power imbalance – Lack of collaboration

31 ….professional Role/Relevance questions – Limited role in decision making – Belief that decisions contradict best interests – Confusion about plan – Too many partners or consultants Communication failures – In team, between teams – Patient or family Sustained proximity when others walk away Technological imperative/futility – Doing everything vs. the right thing Belief doing everything a sign of faithfulness – Death a failure Discomfort with own mortality

32 ….professional Conflict – Assertive/aggressive patients/clients and families – Intra or interdisciplinary conflict Outside pressures – Organizational, professional, personal Economy Pandemic Politics

33 Symptoms of Moral Distress Emotional/psychological – Intrusive thoughts – Disturbing dreams – Sense of reliving trauma – Cued psychological distress Difficulty concentrating Hypervigilance Anxiety Frustration Depression

34 ….symptoms Irritability, anger, insults, blaming Physical – Cued physiological reaction – Fatigue – Somatic concerns – Diminished activity level – Difficulty sleeping Feelings of inadequacy – Personal, professional – Feeling victimized

35 ….symptoms Distancing oneself – Detachment from others – Avoidance of others, places, activities Absenteeism – Emotional numbing – Foreshortened future Poor or inappropriate care – Inability to recall patient/client information Loss of integrity and authenticity Loss of meaning Crisis of faith

36 Organizational Barriers Hospitals/other settings – Cure orientation – Death as failure – Biomedical focus – Technology – Lack of time – Failure of team Leadership dynamics Lack of collaboration Conflict – Patient/client with sudden, critical illness Wishes unknown Sustained proximity when others walk away

37 Organizational Inhibitors Culture(s) that – Stifle discussion regarding unethical behaviors and/or tolerate unethical acts – Willing to compromise personal and professional standards to avoid social isolation from peers to secure a promotion/favoritism within the organization – Group think to turn the other way – Unwillingness to face the tough challenge of addressing unethical behaviors – Redefine unethical behaviors as acceptable – Indifference to ethical values – Apathy of bystanders

38 Work Place Culture Pathologic culture Bureaucratic culture Generative culture – Components Informed/informing Just Flexible Learning What does your culture look like?

39 Organization Symptoms Depression, psychosis screening – Hopeless about the future – Difficulty making decisions – Loss of interest – Agitation – Feeling trapped – Negative vision, risk-avoidance, downplay threats – Lack of care, cause harm

40 Crescendo Effect Solid lines indicate moral distress Dotted lines indicate moral residue Moral Distress Time Moral residue crescendo Moral residue Moral distress crescendo


42 Strategies to Address Moral Distress… Causal analysis Self awareness/self monitoring – Limits, issues Address issues in real time – Debriefing Talk about it – Ethical dialog Referral Skill-building Grief work Engage in work of letting go – At the bedside – Funerals, journal, phone calls – Sacred/holy

43 ….strategies Story telling Self-care – Balance Appropriate boundaries – Spiritual practice Find own voice/advocacy – Courage Develop sources of support – Professional – Referral sources – Social – Play

44 Hard to tell from here. Could be buzzards. Could be grief counselors.

45 Organization Prozac? Insight-top down Shock therapy Organizational soul Admit there is a problem Re-inspire Re-invigorate Re-energize Re-discover roots

46 Self esteem/self confidence Accountability, self-control, and resilience Professionalism/self-development/respect and rational decision making Customer service, patient rights, communication, and teamwork Organizational awareness, performance improvement, information management Cost control, safety, infection control, facility, others Decker PJ. The Hidden Competencies of Healthcare: Why Self-Esteem, Accountability, and Professionalism May Affect Hospital Customer Satisfaction Scores. Hospital Topics. 1999;77:14-26 (1999).

47 Resources to Address Moral Distress Opportunities for breaks Places of sanctuary Real time interventions – One on one – Huddles – Rituals of letting go Consults – Internal, external Support Groups CISM Other forums – Rounds, grand rounds – Round table, journal club – Schwartz Center Rounds

48 Ethics Resources Mission, Vision, Values Code of Ethics Ethics Consultation, Ethics Committee Organization Ethics Committee Compliance Conflict of Interest Committee Institutional Review Board

49 …ethics resources Pastoral care Palliative care Employee Assistance Program Patient advocate Quality improvement Outcomes management Patient safety Risk management

50 Interventions Ethics mechanisms Round table Grand rounds Facilitated ethics conversations Follow up education after consultation Curbside conflict management Mediation Informal, curbside education Monthly brown bags

51 Healing Teams Interdisciplinary/ collaborative – Role modeling – Mentoring – Skill building/capacity – Education Conversation – Affirmation of positive – Encouraging when negative Blessing Flexible and creative Trusting environment – Safe place to talk Bereavement Effective leadership

52 Effective Organizations Recurring and systemic causes identified and monitored – Correct the problem – Targeted interventions Adequate financial and people resources – Ethics resources – Palliative care – Conflict resolution – Interdisciplinary forums to discuss complex situations Mechanisms to address issues Accountability for practice and behavior Skill building, education, mentoring Bereavement mechanism – Where death is frequent

53 Community Resources Grief counseling (through hospice, other) Agencies Crisis lines/centers Counselors, therapists Clergy in the community Who/what have you found helpful?

54 Leadership Responsibility Take bold steps to engage interdisciplinary colleagues to create solutions, monitor progress Develop and implement targeted strategies and evaluate their effectiveness – Involve medicine, nursing, social work, pastoral care, ethics consultants, mental health professionals, palliative care, and other disciplines that have relevant expertise Recognize the symptoms of distress and create opportunities to explore the behaviors and coping strategies

55 …leadership Communication forums, modeling of good communication Engage in systematic review of cases Develop and use support systems Build a trustworthy community, with rewards and recognition, development of strategies for resilience, self-care, renewal, and personal growth Reach out to community Leverage resources and relationships


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