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.