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Bioethics Forum Essay

Improving Ethics at the Bedside

It’s one o’clock in the morning in the pediatric intensive care unit.  A 16-year-old patient tells his nurse that he disagrees with the medical treatment plan that was agreed to by his parents. While he is legally a minor, he may have the capacity to make his own medical decisions. He is scheduled for surgery the next morning, and the nurse wonders how to best help him.

On another night in the PICU, a toddler who was neurologically devastated due to a head trauma sustained in a motor vehicle accident remains unresponsive. She has been in the PICU for a week. After attending a care conference with the medical team earlier in the day, her family is considering withdrawing treatment.  It is now midnight, and the patient’s mother is having trouble falling asleep. She wants to talk to the night nurse who has been caring for her daughter since admission. She and the nurse have developed a good relationship, and the mom asks the nurse what he thinks the best decision is.

These are just a few examples of ethical dilemmas that my peers and I have encountered as inpatient nurses in the PICU. Over our long shifts at the bedside, we develop intimate understanding of our patients and their concerns. As a result, we are often the first members of the clinical team to identify ethical issues. However, despite my years of experience, I have not always been comfortable identifying and discussing the ethical concerns of my patients. A few years ago, with the support of my nursing leadership, I returned to school to obtain further ethics education, and I recently graduated with a master’s degree in health care ethics.

My goal in earning this degree was to better understand the ethical dilemmas of my patients and do a better job of addressing them.  While ethics consultants and scholars are essential to the shaping of inpatient care, having bedside staff with a solid understanding of ethics is also imperative. Hospitals need ethicists to provide education, develop policies, and facilitate resolution of ethical dilemmas, but hospitals also need their bedside staff to identify and discuss ethical issues. Nurses care for the whole person, which includes evaluation of goals and best care, and vigilance for and discussion of potential or actual ethical issues that impact their patients.

Resources such as ethics committees and guidelines are usually available to hospital staff, but bedside nurses need to understand ethics well enough to know how and when to access these issues and to be able to articulate identified ethical issues in a way that prompts meaningful discussion. Ethical discussions are richer if they include many voices and perspectives. Bedside nurses have much to contribute to ethical discussions, but their insights will be more meaningful if they can clearly articulate the issues and place them within a framework of ethical theory and understanding.

Formal ethics discussions are not the only forums in which having nurses with solid ethics education may be beneficial. Because our work involves long shifts at the bedside, nurses are often readily available to patients for informal and impromptu discussions.  Patients and families may turn to a trusted nurse for guidance when an ethical issue is first coming to light. Later, after a formal discussion has taken place, perhaps in the form of an ethics consultation, patients and families may turn to their nurses with additional questions or need for further discussion. (This is common in the middle of the night, when I work, when the bustle of the day has faded, and patients and families have had time to think and reflect).

Unfortunately, bedside nurses are often uncomfortable articulating and discussing ethical issues. While completing a practicum project for my degree, I interviewed many of my fellow nurses about their experiences managing ethical issues. The majority of these nurses told me they lack the necessary resources and education to address the ethical issues of their patients. This was how I felt before I returned to school.

Now, I am better able to help my patients and their families work through their ethical dilemmas and discuss their health care needs and goals. I ask better questions during rounds. I have had important middle-of-the-night conversations with parents who are trying to evaluate what their goals are for their children. I have also been able to talk with peers who are experiencing moral distress and with health care professionals who need to evaluate whether an intervention is beneficial to a patient or prolonging suffering.  Maybe someday I will use my ethics degree in a more formal capacity. For now, though, I’m glad to be a more ethical bedside nurse, who integrates better thinking into the daily care I provide and is able to help work through the ethical issues of my patients.

Pageen Manolis Small is a nurse clinician at the University of Wisconsin Hospitals and Clinics.

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  1. The essence of a Caring Relationship, as in nursing and parenting, is in its shared ethical attributes of beneficence and autonomy as enhanced by its communication with warmth, non-critical acceptance, honesty and empathy. The conditions associated with a dependent child and their parents responsibility to act in their best interests is magnified by what the dependent child might think about these actions when an independent person. Lacking, of course, is a widely accepted definition for a person’s HEALTH that defines a connection between HEALTH and the person’s Family Traditions. What then other than an insightful PICU nurse to compensate for young parents neither of whom have meaningful, supportive Family Traditions?

  2. I appreciate this article, thank you. As an ICU nurse for 16 years and now clinical ethicist at my organization this is very real and not going away. Historically, and many would say currently, healthcare curriculum has not adequately incorporated an ethical framework around medical decision making into the practice of medicine. In the fast paced industry of acute care, we are often coming at patients to do interventions to them, rather than for them. Rarely is the time allowed for meaningful conversation to assess goals of care that are inline with the goals of medicine. We are often treating organs, rather than humans. Nurses don’t have the ethical framework that is imperative to facilitation a conversation with families and patients when the cardiologists can fix the heart, the nephrologist can fix the kidneys but the neurologist can’t fix the brain. Therefore, the front line staff working in the trenches facing these difficult circumstances daily get burned out quicker, lack compassion/empathy and experience moral distress regularly. One way our institution has tackled this lack of preparation for our front line staff is through a program called Ethics Mentors. This is not mandatory, but since its conception we have had over 250 front line staff take the course. This is an 8 hour course focusing on the basic ethical principles (autonomy, beneficence, justice, and non-maleficence) how to applying those principles to various cases, techniques for facilitating conversations with patients and/or surrogates with the ultimate goal for identifying ethical dilemmas sooner. This allows for earlier ethics consultations and mentoring of other staff members who experience moral distress. Sadly, our administration leaders struggle to see the benefit to invest in the program because it’s difficult to measure how this effects the bottom line. I can easily argue that it reduces length of stay, unwanted medical care, earlier admissions to hospice, etc…but that’s difficult to prove on paper. Stay strong nurses! We are all in this together and know you are not alone.

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