ETHICAL DECISION MAKING IN CRITICAL CARE

It is essential that critical care nurses understand professional nursing ethics and ethical principles and that they are able to
use a decision-making model to guide nursing actions.

The Nurse’s Role

Critical care nurse encounters ethical issues on a daily basis. Benner described the concept of the relational ethics of comfort,
touch, and solace and questioned whether it is an endangered art lost to times past. Critical decisions such as the conservative uses
of restraints are another example related to comfort and ethical care of patients. Lachman described the ethics of caring to nursing
practice. Through the very decision to become a nurse, one makes a moral commitment to provide care and services for patients, and
that indicates a focus on meeting all the needs of patients. Pavlish and colleagues studied nurses’ ethically difficult situations, their
early indicators and risk factors, nurse actions, and outcomes. From this study, they derived risk factors for patients, families, health
care providers, and health care organizations. Additionally, they delineated early indicators for ethical dilemmas in six areas.
Acknowledging the importance of the nurse-patient relationship and establishing time to listen, explain, and comfort can
assist the nurse in determining unmet needs of patients. presents the Code of Ethics of Filipino Nurses help clarify values. (See Code
of Ethics of Filipino Nurses.)

EARLY INDICATORS FOR ETHICAL DILEMMAS

Signs of conflict among health care (HC) team members, family members, and HC team and family
• Signs of patient suffering
• Signs of nurse distress
• Signs of ethics violation
• Signs of unrealistic expectations
• Signs of poor communication

Health care organizations and authors have emphasized that responding to individual ethical issues is not enough and that there must
be a plan in place that asserts a systematic approach for proactively addressing ethical situations. This program should identify,
prioritize, and address concerns about ethics at an organizational level. Thus, measurable improvements will be able to demonstrate
reduced disparities between current practices and ideal practices. Epstein described an intervention in which the role of the critical
care nurse is essential in early identification of potential ethical issues, i.e., preventative ethics. Sample questions to consider are listed
in sample questions to trigger preventative ethics intervention.

SAMPLE QUESTIONS TO TRIGGER PREVENTATIVE ETHICS INTERVENTION

1. Is the patient able to contribute to decisions about his or her care?
2. Is the patient still in critical condition 48 hours after admission?
3. Has the patient’s family visited in the last 48 hours?
4. Are the patient and family non-English speaking, or are they members of a cultural group that is unfamiliar to most
providers on this unit?
5. Has the family been updated by the team in the past 24 hours?
6. Has today’s bedside nurse cared for this patient before?
7. Has the bedside nurse established rapport with this patient and family?
8. How many different nurses have cared for this patient in the past week?
9. Has the family stated strong religious beliefs that could potentially conflict with medical treatment?
10. Is there consensus among the team members with regard to this patient’s prognosis and treatment plan?
11. Are there any unit routines or procedures that negatively affect this patient’s care?
12. Is this patient’s situation ethically challenging at present?

A normal routine for nurses done on a daily basis is the incoming and outgoing “hand-offs” of patient reports. Rushton reports
that nurses could overlook common issues and potential ethical violations. Rushton offers several strategies to ensure an ethically
grounded nursing shift report. Additionally, a patient care issue that arise when a critically ill patient needs a surrogate decision maker.
It is especially difficult when a patient has no family member or is otherwise from a vulnerable and/or marginalized population.
There are major concerns when clinicians serve as both the clinical and the surrogate for the patient.
The decision must be made by someone other than the treating clinician, considering procedural fairness for the situation.

STRATEGIES FOR NURSING SHIFT REPORT

• Monitor language and tone
• Challenge assumptions
• Be alert to the presence of gossip
• Develop professional norms
• Hold yourself and one another accountable
• Use a standard framework
• Adopt a “need-to-know” policy

Ethical conflicts occur frequently in the health care setting. These can stem from negative outcomes, conflicts that can affect areas
of staff morale, operational and legal costs, and public relations. It is essential that the health care organization has methods in place
to address ethical issues. Because the nurse is on the front line with issues such as do not resuscitate (DNR) orders, response to
treatments, and application of new technologies and protocols, nurse may be the one person who best knows the patient’s and
family’s wishes about treatment prolongation or cessation. It is therefore important that the nurse be included as a member of the
health care team that determines ethical dilemma resolution.

What Is an Ethical Dilemma?

In general, ethical cases are not always clear-cut. An ethical dilemma exists if there are two (or more) morally correct actions
that cannot be followed. The result is that both something right and something wrong occur. In these situations, there are both ethical
conflict and ethical conduct issues. The most common ethical dilemmas encountered in critical care are forgoing treatment and
allocating the scarce resource of critical care, but how does the health care worker know that a true ethical dilemma exists?
Before any decision model is applied, it must be determined whether a true ethical dilemma exists. The criteria for defining
moral and ethical dilemmas in clinical practice are threefold:
1) an awareness of the various options;
2) an issue that has options; and
3) two or more options with true or “good” aspects, with the choice of one option compromising the option not chosen.
One must pause, expand group consciousness about the issue, validate assumptions, look for patterns of thoughts or
behaviors, and facilitate reflection and inquiry prior to making any decision.

Steps in Ethical Decision Making

To help facilitate in the ethical decision-making process, a model or framework must be employed so that all involved will
consistently and clearly examine the multiple ethical issues that arise in critical care. There are various ethical decision-making models
in the literature. The steps in an ethical decision-making model that will be briefly discussed in this chapter.

STEPS IN ETHICAL DECISION MAKING

1. Identify the health problem.
2. Define the ethical issue.
3. Gather additional information.
4. Delineate the decision maker.
5. Examine ethical and moral principles.
6. Explore alternative options.
7. Implement decisions.
8. Evaluate and modify actions.

Step One
The major aspects of the medical and health problems must be identified. In other words, the scientific basis of the problem, potential
sequelae, prognosis, and all data relevant to the health status must be examined.

Step Two
The ethical problem must be clearly delineated from other types of problems.
Systems problems result from failures and inadequacies in the health care facility’s organization and operation or in the health
care system as a whole and are often misinterpreted as ethical issues.
Social problems arising from conditions in the community, state, or country as a whole also are occasionally confused with
ethical issues.
Social problems can lead to systemic problems, which can constrain responses to ethical problems.

Step Three
Although categories of necessary additional information vary, whatever is missing in the initial problem presentation should be
obtained. If not already known, the health prognosis and potential sequelae should be clarified. Usual demographic data—age,
ethnicity, religious preference, and educational and economic status—may be considered in the decision-making process. The role of
the family or extended family and other support systems must be examined. It is essential to ascertain any desires the patient might
have expressed about the treatment decision in writing or in conversation.

Step Four
The patient is the primary decision maker and autonomously makes these decisions after receiving information about the alternatives
and sequelae of treatments or lack of treatments. However, in many ethical dilemmas the patient is not competent to make a decision,
such as when the patient is comatose or otherwise physically or mentally unable to make a decision. It is in these situations that
surrogates are designated or appointed by a court if the urgency of the situation requires a quick decision. Others who are involved in
the decision, such as the family, nurse, physician, social worker, clergy, and members of other disciplines having close contact with
the patient, need to be identified at this time. The role of the nurse must be examined. It may not be necessary for the nurse to make
a decision at all; rather, the nurse’s role may be simply to provide additional information and support to the decision maker.

Step Five
Personal values, beliefs, and moral convictions of all involved in the decision process need to be known. Whether actually achieved
through a group meeting or through personal introspection, values clarification facilitates the decision process. See the NIC feature
on values clarification in Box 2-6. The professional ethical codes of the nurse and physician will serve as a foundation for future
decisions. At this time, legal constraints or previous legal decisions regarding circumstances at hand need to be assessed and
acknowledged. General ethical principles must be examined in regard to the case at hand. For instance, are veracity, informed consent,
and autonomy being promoted? Beneficence and nonmaleficence should be analyzed as they relate to a patient’s condition and
desires. Close examination of these principles may reveal any compromise of ethical or moral principles for the patient or the health
care provider and can assist in decision making.
Step Six
After the identification of alternative options, the outcome of each action must be predicted. This analysis helps the nurse to select
the option with the best fit for the specific situation or problem. The short-range and long-range consequences of each action must
be examined, and new or creative actions must be encouraged. Consideration also must be given to the “no action” option, which is
another choice.

Step Seven
A decision is reached, usually after much thought and consideration, and the decision is implemented. Close attention to detail of the
agreed-upon plan is essential. All members of the health care team must be updated, along with the family. It is important that there
be one family member designated as the “liaison” between the team and all family members. Ongoing frequent, accurate
communication is essential, as well as support for the family and caregivers.

Step Eight
Evaluation of an ethical decision assesses the decision at hand and provides a basis for future ethical decisions. If outcomes are not as
predicted, it may be possible to modify the plan or to use an alternative that was not originally chosen. The case can then be reviewed
for implications in future ethical interventions and education of the health care team.

Ethical Reasoning Sequence

Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide
justification for actions based on principles.
1. First, the nurse determines whether or not the issue involves an ethical dilemma and gathers information that is relevant to
the case.
2. Next, the nurse undertakes personal value clarification and identifies his or her own values regarding the issue.
3. Third, the nurse verbalizes the problem in a simple sentence.
4. Fourth, the nurse considers possible courses of action. In this case, the nurse may choose to seek the counsel of the
agency’s ethicist regarding the issue.
5. Fifth, the nurse negotiates the outcome by developing a confidence in her or his own point of view with deep respect for
the opinions of others. In this case, the nurse may negotiate with the family to determine a course of action that will allow
the nurse to preserve integrity and yet allow the family to determine when the client should be informed of the tragic loss.
6. Finally, the nurse evaluates the action.

Ethical Reasoning Sequence

1. Gather all of the information relevant to the case.

2. Examine and determine one’s own values on the issues.
3. Verbalize the problem.
4. Consider possible courses of action.
5. Negotiate the outcome.
6. Evaluate the action.

STRATEGIES FOR PROMOTION OF ETHICAL

DECISION MAKING

The complexity of health care and ethical dilemmas encountered frequently in clinical practice demand the establishment of
mechanisms used to address ethical issues in hospitals and health care facilities. Four types of mechanisms are discussed briefly here:
institutional ethics committees, in service and education programs, nursing ethics committees, and ethics rounds
and conferences.

Institutional Ethics Committees

Although they are not required by law, many health care facilities have developed institutional ethics committees (IECs) as a way to
review ethical cases that are problematic for the practitioner. Major functions of IECs are education, consultation, and
recommendation to policy-making bodies. An IEC may function in a variety of ways. The committee may serve as consultants and
make recommendations that are not binding. In other situations, health care providers may be required to consult with the committee
when there is an ethical problem, with recommendations again not being binding. The third approach requires that ethical dilemmas
be presented to the committee and that the recommendations made by the committee must be followed. Regardless of the type of
IEC, ethics consultations can help to resolve conflicts that may otherwise prolong unwanted or nonbeneficial treatments.
IECs very often comprise executive medical staff. Membership may include staff physicians, administrators, legal counsel,
nurses, social workers, clergy, and community public volunteers. To fulfill its requirement for consultation, the committee must include
members who not only have expertise but also are representative of various groups. Regardless of the type of committee model, the
IEC provides consultation and support to the practitioners.

Inservice and Education Programs

Basic education about ethical principles and decision making is an important first step in facilitating ethical decision making
among nursing staff in the critical care area.32-33 It is important for nurses to examine their own values, beliefs, and moral convictions.
Nurses need to know and use the ANA Code for Nurses in their daily clinical practice. Treatment choices for patients and ethical issues
involving patients, nurses, and medical colleagues must be explored and discussed in the classroom setting, where no time constraints
or extraneous distractions exist to interrupt the decision-making process. Use of the nursing process as a framework can be a teaching
strategy for understanding ethical issues.
ETHICS AND THE NURSING PROCESS

Initial Steps: Clarify and Define the Nature of the Problem

• What is the crisis (or dilemma) requiring a decision?

Assessment: Identify Key Facts and Values That Are Applicable

• What are the crucial facts of the case?
• What moral principles are at issue here?
• What decision-making procedure is appropriate?

Planning: Explore Available and Best Means to Reach Our Goal

• What is the primary aim or good for which we are acting?
• What objectives, benefits, and moral goals are achievable?
• What previous cases or contingencies should we take into account?

Implementation: Take Decisive and Effective Action to

Implement Plan
• How do we begin, continue, and finish the process of intervention?
• How do we assess costs/benefits of the intervention?
• How do we monitor success/failure in the overall process?

Evaluation: Evaluate Progress and Outcomes with Planned

Objectives
• What means have we set up for debriefing and feedback?
• Have we used the “right” means to a “good” end?
• How do we review the pros/cons for the action taken?

Final Steps: In Retrospect, Apply the Following Tests

• Could I/we provide a reasonable ethical justification for the course of action taken?
• Can I/we identify what we have learned from applying this model to decision making?
• How do we integrate this learning into the next decision-making cycle?

Nursing Ethics Committees

Nursing ethics committees provide a forum in which nurses can discuss ethical issues that are pertinent to nurses at the
individual, the unit, or the department level. Unlike the IEC, which involves treatment choices for patients, the nursing committee may
or may not address a patient situation. Depending on the specific goals of the committee, it can also serve as a resource to nursing
staff, make recommendations to a policymaking body about a variety of professional issues, or actually formulate policies. It also may
serve to educate the department on ethical and professional issues. Membership usually comprises representatives from all major
clinical areas or divisions, educators, clinical nurse specialists, administrators, and other specialty staff. Some departments, such as
critical care, may have their own unit or division committee.

Ethics Rounds and Conferences

Ethics rounds at the unit level regarding patients in the unit can be done by nurses on a weekly or other established basis.
Rounds educate the staff about problems and can have preventive effects when facilitated appropriately. During the discussion,
potential problems may be identified early, and actions may be taken to decrease or prevent the incidence of a problem. An individual
patient ethics conference may be scheduled to include only the nursing staff or to include a multidisciplinary group to discuss unit
issues. A patient ethics conference may function as a liaison with the IEC or as an end in itself.

SUMMARY

• Ethical dilemmas are encountered daily in the practice of critical care.

• The Cod of Ethics for Nurses provides the foundation statement on moral distress and framework to address moral distress
provide insight and guidelines for critical care nurses who experience moral distress.
• The critical nature of the situation and the speed that is required to make decisions often prevent practitioners from gaining
insight into the desires, values, and feelings of patients.
• By assuming a solely technologic approach, practitioners violate the rights of patients and their professional codes of ethics.
• By using an ethical decision-making process, practitioners protect the rights of the patient, and logical analysis of the case leads
to a decision that is made in the best interests of the patient.
• It is through moral reasoning and examining, weighing, justifying, and choosing ethical principles that patient’s rights and
individuality are upheld.
• The practice of nursing is built on a foundation of moral and ethical caring; the critical care nurse is pivotal in identifying patient
situations with an ethical component and can participate in the decision-making process to address the issues.

CASE STUDY
Patient with Ethical Dilemma

Brief Patient History

 Mr. X is a 67-year-old obese male. He has a 2-year history of emphysema (100 packs/year history of tobacco abuse in the
past) with two recent hospitalizations for pneumonia that required ventilatory support. Mr. X states that he does not want to be
placed on a ventilator again but does not want to suffer either. He was involved in a motor vehicular accident (MVA) and sustained
blunt trauma to his trunk and lower extremities, with bilateral femur fractures.
Although his condition is critical, he is expected to recover. Mr. X received morphine 5 mg by intravenous push in the
emergency department, with minimal pain relief; however, he has experienced new-onset confusion. Mr. X’s spouse and children
express concern about the risk of respiratory depression due to pain medication. They state that they would rather Mr. X experience
pain than have him placed on the ventilator again.

Clinical Assessment
Mr. X is admitted to the critical care unit from the emergency department with blood transfusions in progress. Buck’s traction
(5 pounds) has been applied to both lower extremities. He is awake, alert, and oriented to person, time, place, and situation. Mr. X is
breathing through his mouth, taking shallow breaths. He complains of right upper quadrant abdominal pain when taking a deep breath.
His skin is warm and dry. Mr. X is able to move his toes on command, and lower extremity sensation to touch is intact; however, he is
complaining of severe bilateral lower extremity pain with restlessness.

Diagnostic Procedures

Arterial blood gases: PaO2, 55 mm Hg; PaCO2, 28 mm Hg; pH, 7.35; HCO3−,24 mEq/L; O2 saturation, 88%.
Hematocrit, 24%; hemoglobin, 8 g/dL. Patient reports pain as a 10 on the Baker-Wong Faces Scale. Riker Sedation-gitation Scale score
= 5.

Medical Diagnosis
Mr. X is diagnosed with a hepatic hematoma and bilateral femur fractures from an MVA.

Questions
1. What major outcomes do you expect to achieve for this patient?
2. What problems or risks must be managed to achieve these outcomes?
3. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?
4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?
5. What possible learning needs would you anticipate for this patient?
6. What cultural and age-related factors might have a bearing on the patient’s plan of care?