Something Doesn’t Feel Right: A Case Study on Moral Distress GRACE KELLY, BSN, RN-BC, CLIII NURSING GRAND ROUNDS DECEMBER 14, 2012

Abstract Health care professionals face a variety of challenging situations throughout their careers. Occasionally, situations present themselves that have severe ethical and moral implications. This presentation will focus on the phenomenon of moral distress by examining a case study that presented many moral and ethical challenges for the health care team involved.

Abstract Moral distress occurs when a health practitioner feels they know the ethically appropriate course of action, but is unable to carry it out. This can leave a moral residue with feelings of frustration, anxiety, compromised integrity, and a variety of other feelings that will be examined throughout the presentation. As this is a rarely discussed phenomenon, healing can often come simply by the recognition of these symptoms in a given situation.

Abstract While this hour will focus on nursing, it has implications for physicians, physical and occupational therapists, as well as the rest of the interdisciplinary team.

Objectives Identify moral distress and its causes Identify 3 strategies for coping with moral distress

Ethics 101 Non-maleficence - the obligation to do no harm Beneficence - the moral obligation to act for the good of others Autonomy - respecting the right of all people to make choices and decisions based on their individual beliefs and values Fidelity - faithfulness, particularly the duty to honor commitments made to others Justice - all people deserve to be treated fairly and available resources should be used equally

Ethics 101 Moral distress Examples Include The psychological disequilibrium that occurs when a person believes he/she knows the right course of action, but cannot carry out that action because of some obstacle. institutional constraints lack of power lack of resources and/or support legal limits when nurses disagree with a course of action that has been chosen inability to complete basic nursing function/role conflict of use of resources, violation of personal morals/values, etc Separate this slide?? Have it on it’s own

3 Categories of Ethical Issues Moral uncertainty Moral dilemma Often the earliest response; occurs when caregiver feels something is not right or is uncertain about a particular course of action. May manifest as questioning, discomfort, tension, or frustration The clinician does not know the ethically correct choice, but feels a nagging uncertainty, a sense that something is not quite right. When two or more opposing actions can be equally justified and the agent, unable to carry out both actions, faces a dilemma in choosing which ethical course to follow.

Moral Distress Moral distress – the clinician feels they know the right course of action but feels constrained from acting out because of some obstacle.

Why does this matter? ANA Code of Ethics Provision 1: The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems Provision 2: The nurse's primary commitment is to the patient, whether an individual, family, group, or community.

Why does this matter? ANA Code of Ethics Provision 3: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient Provision 5: The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

Case Study 33 y/o male with multiple, long-term admissions to the hospital for sepsis related to major stage 4 decubitus ulcers on his coccyx, sacrum, hips, and bilateral lower extremities. Over the course of 4 years, CP would get admitted for antibiotics and electrolytes, as well as placement assistance. Due to his complex wound care needs, placement was difficult and he eventually started refusing.

Case Study, Continued He would come into the hospital for several weeks, become stable, and be discharged with home health or something in place for his wound care. Readmissions were frequent due to repeat infections. Throughout his hospitalizations, several treatment options were explored, including a radical hemipelvectomy. He was determined to not be a candidate due to his fragile health status.

Case Study, Continued In early admissions, he had good relationships with the staff; he was energetic, friendly, and participated in care. In the final few years of his life, he became increasingly labile in his goals of care, attitude, and treatment of staff. He became verbally abusive and demanding. His family would, at times, pose physical and verbal threats to staff.

Case Study, Continued The care team established a clear care plan – with nurse rotations, required care, and mutual respect goals – to prevent burnout and abuse. Staff were to go into his room two-by-two, offer care only once, and leave immediately if he refused or became abusive.

Case Study, Continued He eventually developed a seizure disorder and started becoming more receptive to the idea of palliative care. The care team tentatively started discussing this idea when he had another seizure that made him incapacitated. As CP had not established an Advanced Directive or POLST, medical decisions were deferred to his mother. She had not been a frequent visitor throughout his years in the hospital and had a known drug and alcohol problem.

Case Study Continued The medical team was uncomfortable with her now being the principle decision maker, however, the law is clear in this category. She insisted on full treatment. CP had a former girlfriend who had been very involved in his care from the beginning and was realistic about his prognosis. She was advocating for palliative care, but was not a decision maker. She continued to visit him throughout this stage and was a valuable advocate for the medical staff.

Case Study, Continued Once CP awoke from his “trance”, he refused all care, but no longer wanted to pursue palliative care. Staff became increasingly frustrated with providing care for him. He was refusing all the treatments he was in the hospital for, including basic hygiene and room cleaning. We continued our care plan until his DC. C.P. eventually discharged back home; several months after his final discharge, he was admitted to Emanuel and passed away.

Our Concerns As nurses we faced much frustration about this case: Why was he permitted to stay and receive care if he was refusing everything we had to offer? Taking up an expensive bed, using valuable staff? As nurses, our role is to provide care to those who need it and want it; this patient desperately needed it, but was refusing. We were unable to fulfill our perceived duty as nurses, medical staff, and interdisciplinary care givers.

Our Concerns What we did to ease our concerns: Ethics consult Connections consult Debriefs when needed Pastoral care

Discussion What are the moral issues seen within the case? Interdisciplinary Perspectives Physicians Care Management Rehab services Pharmacy

NOW WHAT??

Identification Initial Moral Distress Reactive Distress initial moral distress: first encounters the situation and senses that "something is wrong -- I shouldn't be party to this” reactive distress: this is what the clinician feels about their inability or failure to act on the initial distress

Moral Residue Distressing feelings that linger after the situation if the caregiver feels regret

Symptoms Frustration Anxiety Guilt Compromised integrity Psychological disequilibrium

Admitting You have a Problem is the First Step Initial Steps in treatment Recognition and naming moral distress Increase self-awareness of strengths and weaknesses SPEAK UP! Self advocacy – insist on a dialogue with the other people involved Get the whole story Identify the Values in Conflict Whose values? What is their relationship to the patient?

Solutions Talk about your concerns openly to help identify them Offer safe, confidential debriefs whenever necessary “Time to Talk” – group debriefs with the care team Care conferences Include the entire care team and patient Involve Pastoral Care

Solutions Seek an ethics consult when appropriate – in ethics consults, if everyone is looking for the ethical dilemma but the real issue is moral distress, it may be misdiagnosed and the problem is not treated. At one point in his hospitalizations, nursing placed an ethics consult; it was cancelled due to a lack of an identifiable ethical dilemma. We did not know at the time we were feeling moral distress.

Questions?

References Hamrick, A.B., Davis, W.S., & Childress, M.D., (2006). Moral distress in health care professionals: What is it and what can we do about it?. Pharos, 16-23. Choen, J. S., & Erickson, J. M. (2006). Ethical dilemmas and moral distress in oncology nursing practice. Clinical Journal of Oncology Nursing, 10(6), 775-780. Ferrell, B. R. (2006). Understanding the moral distress of nurses witnessing medically futile care. Oncology nursing forum, 33(5), 922-930. Beumer, C. M. (2008). Innovative solutions: The effect if a workshop on reducing the experience of moral distress in an intensive care unit setting. Dimensions of critical care nursing, 27(6), 263-267.