Nurses are the clinicians who spend the most time with hospitalized patients.
When a chief nurse executive introduced the concept of nurses collaborating with physicians on ethics, nurses saw an opportunity and the system became more responsive.
The following case study is included in The Nurse’s Healthcare Ethics Committee Handbook, published by Sigma Theta Tau International Honor Society of Nursing (Sigma):
A 54-year-old female is admitted to the hospital with septic shock. She has a history of stage IV colon cancer and is receiving in-home hospice services. The patient is currently in the ICU on a ventilator and not able to make decisions for herself. The small bowel and the bladder have developed a fistula between them leading to profound sepsis (blood cultures are positive). A friend of the patient is listed as the emergency contact and the healthcare power of attorney. A copy of the healthcare power of attorney is on the chart. This friend, however, declines to participate in the patient’s healthcare decisions, citing difficulties with the patient’s family. The patient’s sister becomes involved and insists on full medical intervention. (Dewey & Holecek, 2018, p. 117)
This scenario plays out frequently in hospitals across the United States and elsewhere. Imagine being part of the healthcare team involved in this case. How would you feel? The nurses caring for this patient may feel a variety of negative emotions, including frustration, anxiety, and anger. How should the healthcare team move forward with this difficult situation?
Early in my career, when these kinds of circumstances arose, I would often take a deep sigh, close my eyes to gather my thoughts, and then ask myself, “What in the world are we doing to this poor patient?” My mind would race as I contemplated all the interventions modern healthcare could perform. And then would come another question: “Should we be doing all these things?”
As a new nurse, I was shocked at the amount of resources and hospital days this patient would accumulate. How, as a healthcare team, can we let this go on? Surely someone on the team will speak up if this isn’t right, won’t they? After all, taking care of patients at all costs is what acute-care hospitals do, right?
As a seasoned nurse, I’m no longer shocked. I know from the beginning how this case is likely to end. There is no guaranteed cure from cancer. The patient will die and probably suffer through the entire drawn-out process.
After 20 years as a nurse caring for adults in critical care, the expert in me now approaches such cases from a different angle. Many years ago, a very wise colleague shared a secret with me that has kept me grounded when encountering similar stories:
Patients and their families typically do not know what we, as healthcare providers, know. They cannot even begin to have the perspective that we have acquired in dealing with the complex scenarios that confront us almost every day. They haven’t spent the many days and shifts in clinical settings we have, where we observed healthcare crises playing out over and over. Pamphlets, web searches, and counseling will not provide the unique perspective that we, as nurses, have in caring for patients as their lengthy hospital stays play out.
We say, “I would never do that to my family.” Well, you know how these situations go. As a healthcare provider, you know that miracle recoveries seldom occur, and perfect-ending medical dramas often seen on TV or in movies are a rarity.
Patients and families can only make decisions based on their knowledge, values, and trust. It takes a leap of faith for a patient or family member who already feels vulnerable and scared to place trust in a caregiver. And it’s even more difficult when receiving a diagnosis or recommendation he or she is not ready to hear.
So what do we do? How should we handle opposing opinions about the care of patients who cannot make their own decisions?
Even though the patient has stage IV colon cancer and was receiving hospice services at home, the family wants healthcare providers to do everything possible to keep their loved one alive. As healthcare providers, most of us would say that the patient is not going to improve, and the focus should be on making the most of the time that the patient has left. Stop the machines and let him or her be comfortable. These are opposing opinions. Which is right? Frankly, neither. This is a situation where there is no right or wrong, and application of basic ethical principles is needed to guide patient care.
Although the study of medical ethics dates back to Hippocrates in the fifth century B.C., centuries of medical and societal development, world politics, increasing complexity of healthcare, and social media all influence modern-day application of ethical principles.
Regarding the scenario posed at the beginning of this article: As an expert nurse on a healthcare team, I recommend consulting your hospital’s ethics committee. Ethics committees are not a new feature in American hospitals, although they vary in structure and concept.
A different approach
The Nurse’s Healthcare Ethics Committee Handbook takes a novel approach to hospital-based ethics committees. As the book’s authors, Andrea Holecek, EdD, MSN, MBA, RN, NE-BC, FACHE, and I urge nurses across the globe to become the core consultants for healthcare ethics problems encountered in the acute care setting.
Nurses are the clinicians who spend the most time with hospitalized patients and therefore are their primary providers. In many organizations, nurses are empowered to make positive changes that drive optimal patient outcomes. Thus, an ethics committee led by and structured around nurses—with nurses performing the consultative service—is an untapped specialty. Nurses performing this role can successfully assess ethical challenges, provide education, coordinate stakeholder meetings, facilitate dialogue, provide key recommendations, and reevaluate cases.
The Nurse’s Healthcare Ethics Committee Handbook is divided into two parts. The first part provides a background in healthcare ethics, which is key to understanding and applying ethical principles. Included in this section are a review of ethics theories, historical development of healthcare ethics, and landmark cases that have helped shape modern healthcare. The second part of the book provides insight into current healthcare ethics practice and challenges along with a comprehensive design and process plan for creating a nurse-led ethics committee. Chapters in this section are sure to inspire nurse leaders to consider the full potential of nurses to drive the ethics consultative process in acute care settings. Also included is a chapter of ethics case studies with discussion questions that guide readers through the process of conducting an ethics consult and making recommendations.
From physician-led to nurse-led
The book recounts the evolution of the nurse-led ethics committee at Bayhealth Medical Center in Delaware (USA), a process that took more than five years. Previously, physicians led the ethics committee at our hospital, and they performed the consultative service. Quarterly ethics meetings in which physicians reviewed cases with the interdisciplinary team included only one staff nurse.
When our hospital began its Magnet journey, our chief nurse executive introduced the concept of nurses collaborating with physicians for ethics consults. Several nurses became part of the ethics committee and began partnering with physicians to perform consults. However, even with the addition of nurses, physicians remained the primary drivers. They performed the assessments, interviews, and documentation while nurses shadowed and supported the process. Over time, the number of physicians on the committee dwindled, and nurses on the committee took the opportunity to advance their role by filling the void and performing the ethics consults.
Their roles reversed. Nurses assumed the role of primary ethics consultants, and physicians served as resources. Meanwhile, the ethics committee continued to grow and evolve. One policy change was that any member of the ethics committee was eligible for election as chairperson. Another was that the four primary ethics nurse consultants who serve on the committee rotate ethics call responsibility throughout the year.
Learning and changing
Having served on the ethics committee for more than eight years, I have witnessed and been part of this evolution. Initially, there was significant need for collaboration and ongoing education to provide optimal ethics consultation. To ensure consistency, the nurses developed a standard process for conducting ethics consults. They also improved consult documentation by incorporating it within the electronic health record (EHR).
As part of the documentation, the nurses address the fundamental ethical principles of autonomy, beneficence, nonmaleficence, justice, and fidelity as they apply to the patient situation. This continually reinforces the healthcare ethics knowledge of the consultants as well as other members of the healthcare team. The process also assists the nurse consultant in determining rationale for case recommendations.
Most recently, as an ethics consult is performed, committee members conduct a conference call as an interprofessional team and, within 24 hours, come to a consensus. This conference call enables concurrent case review by the committee as opposed to the retrospective review used in formal meetings.
The current ethics committee at Bayhealth is quite robust, with numerous nurses expressing interest in becoming members. To facilitate succession planning, nurses who want to participate are invited to attend a formal meeting of the committee, where they begin their immersion as ethics nurses.
The rest of the story
From The Nurse’s Healthcare Ethics Committee Handbook, here’s the rest of the case study cited at the beginning of this article:
The ethics nurse discusses the current state of the patient’s care with the primary nurse and the consulting physician. A review of the EHR does confirm that the friend is the designated healthcare power of attorney. There is no evidence of an advance directive, living will, or MOLST [Medical Orders for Life Sustaining Treatment]. The ethics nurse begins by again contacting the friend listed as the healthcare power of attorney. The friend again declines to participate. The ethics nurse then contacts the sister, who is the only other person listed as a contact in the patient’s chart. After speaking with the sister via telephone, it is apparent she did not have much knowledge about the patient’s medical condition. The patient is not married but does have a son who is en route to the hospital after having been contacted by the sister. The son becomes the legal surrogate decision-maker according to the state law. After he arrives, the ethics nurse meets with him, along with the attending physician and the oncologist, to fully explain the medical diagnosis and current condition. The oncologist explains that the patient was status post a bowel resection, full course of chemotherapy, and radiation. Given the current circumstance of septic shock, the patient is unable to receive any more treatment for the cancer, which has reoccurred. The son is not very close with his mother and is devastated by the news, as he was not aware of the gravity of the situation. The ethics nurse explains that the team was not clear about what the patient’s wishes would be in terms of her care goals. She also discusses the vast difference between in-home hospice care and full medical care in an ICU for a terminal disease. Further complicating things, however, is that during her past hospitalizations, the patient expressed wanting “to fight” and verbalized wanting full code status.
During the meeting the son requests that the patient receive any intervention medically necessary. It is times such as these that healthcare providers may struggle the most and can experience moral distress. As experienced clinicians, they know the outcomes of this case will result in patient demise, given the extensive disease process and terminal diagnosis. Yet sometimes patients and/or surrogates choose to continue with futile care. There are a number of reasons for this, including distrust of the medical team, religious beliefs, individual values, need for hope, and lack of knowledge and/or experience. Autonomy, or the ability for the patient/surrogate to make his or her own decisions, will always prevail as the number one guiding principle in ethics. Healthcare providers are obligated to provide information and education to patients/surrogates throughout the decision-making process. It can be distressing for clinicians to support the decisions of patients/surrogates when the choices create discord with the provider’s own values. Healthcare providers must recognize the difference between their values and the choices made by patients/surrogates. In this realization, providers learn to separate their personal values from others and respect the choices made by patients/surrogates as personal choices.
Over the next few days the patient becomes more awake and is able to follow commands as well as answer yes and no questions appropriately while on the ventilator. The team decides to have a discussion with the patient and her son about the overall prognosis and goals of care. During the meeting at the patient’s bedside, with her participation, it is established that the patient wants to continue with full medical care. …
The patient stabilizes and is extubated, after which she continues to express her wishes for full medical care. However, within a week her breathing becomes labored. When asked about placing the endotracheal tube back in, she declines. Subsequently, her level of consciousness deteriorates along with her vital signs. Her son is contacted, as she can no longer make her own medical decisions. He decides to decline cardiopulmonary resuscitation, and the patient dies a short time later. (Dewey & Holecek, 2018, pp. 118–121)
Angeline Dewey, MSN, RN, APRN, ACNS-BC, CCRN, CNRN, is director of education for Bayhealth Medical Center. She has been an active member of the ethics committee at Bayhealth since 2009 and currently holds the chairperson role. She previously held the roles of clinical nurse specialist for the ICU and neurosurgical ICU, clinical educator for critical care, and staff nurse and preceptor in the same organization. RNL
Dewey, A., & Holecek, A. (2018). The Nurse’s Healthcare Ethics Committee Handbook. Indianapolis, IN: Sigma Theta Tau International.