Considering Ethical Issues in Practice

An elderly man is admitted to the hospital with a fungal infection. Infectious disease specialists prescribe a powerful medication that causes severe side effects. The patient’s family voices concerns and asks to stop the medication. The Infectious Disease team advises otherwise. The patient cannot speak for himself.

What’s a nurse to do?

Ethical issues like this often leave nurses in the middle, says clinical nurse specialist Kelly Haight, MSN, APRN.

“Nurses want to advocate for patients and families, but it’s hard to know what to do when a team of doctors wants to take things another way,” says Kelly Haight, MSN, APRN. “Moral distress has a huge impact on nurses. When you think you know what’s right for a patient but don’t see it carried out, it affects your ability to do your job. And it can lead to burnout.”

Discussing real-life controversies

A staff nurse on one of Haight’s floors, Brandee Reese, BSN, RN, has a passion for nursing ethics. Reese minored in philosophy while earning her BSN and later took an ethical nursing class upon joining Cleveland Clinic. Soon after, she suggested that ethics rounds could benefit nurses on her multispecialty step-down unit.

Reese’s supervisor loved the idea and urged her to pursue it. Cleveland Clinic’s Director of Clinical Ethics, Martin L. Smith, STD, offered his support as well. Dr. Smith had helped lead ethics rounds before, for nurses working on intensive care units. Ethics rounds on intermediate care units would be a first for nurses.

To help champion the cause, Reese recruited other nurses from her unit, including Zoe Zelazny, BSN, RN, who has a master’s degree in ethics and policy studies.

“Dr. Smith helped us get things started,” says Reese. “Initially we invited nurses from our floor and the nearby heart and lung transplant floor and met every two weeks. In advance, we’d send an email or talk to nurses about cases they’d like to discuss — often situations currently happening on the floor.”

Reese and her team would type up a case study and send it to Dr. Smith, who would enlist bioethicists from Cleveland Clinic’s Department of Bioethics and other experts to share experiences and insights at the nurses’ next meeting.

“The forums allowed nurses to share their concerns about patient care in a safe environment,” says Dr. Smith. “They also pushed them to think creatively, from an ethics perspective, about appropriate steps to help the patient and future patients in similar situations.”

Out of these “ethical reflections,” according to Dr. Smith, comes “collective wisdom” and empowerment for nurses. “Often, someone would say, ‘Oh, I didn’t think of it that way before, but I will next time,’” says Reese.

‘If Bioethics were involved, how would they handle this?’

The rounds also made nurses more aware of Cleveland Clinic’s Ethics Consultation Service, which they can access as needed. Before ethics rounds, it was typically nurse managers who would request the Ethics Consultation Service — and usually only when situations would escalate and tensions would rise.

“Ethics rounds have shown our nurses how to align situations with an available resource, rather than feeling helpless or that they’re not advocating adequately for their patients,” says Haight. “There is help.”

But discussions have been just as valuable, adds Zelazny. “Even when we don’t call on the Department of Bioethics for help, we have become more able to think about how Bioethics would handle a situation,” she says.

The difference: one year later

It has been more than a year since these ethics rounds began. Haight is leading a research study, “The Effects of Nursing Rounds on Nurse Perceptions.” Data are being collected through nurse instruments. Data analysis is the next step.

“Regardless of the study results, we’ve already noticed a difference in our staff nurses,” says Haight.

“We can be more comfortable in situations, knowing we don’t have to manage alone,” says Reese. “We are better prepared to discuss morally distressing situations with families and are better able to advocate for our patients.”

The Department of Bioethics team is now more involved in patient cases than it used to be, she adds.

“Nurses now know they can do something more than just empathize with patients,” says Zelazny.

Spreading the word

Today, the intermediate care units have ethics rounds once a month at 8 a.m., so both day- and night-shift nurses can attend. Up to 20 attend each half-hour meeting.

“Time is a nurse’s most valuable treasure,” says Haight. “The fact that our nurses are taking time to attend these meetings is proof they value them.”

Will ethics rounds spread to other units? “I recommend ethics rounds for nurses on any unit where risk of moral distress and burnout is highest,” Dr. Smith advises nursing leaders nationwide. “ICUs and intermediate care units, which often have more complex patient cases, may be the first places to consider.”

It doesn’t need to be a huge program, says Zelazny, noting that a good start might be having someone from a hospital’s ethics consultation service or committee come and talk to a handful of nurses.

Better for everyone

As for the elderly patient in the scenario above, he ended up transferring to an intensive care unit, where he passed away, despite having the controversial medication removed.

Nurses studying this case learned to be more proactive in generating discussions among patient families, medical services and Cleveland Clinic’s Ethics Consultation Service— including involving the consultation service early in a conflict.

“When patients and families know they’re being heard, and nurses take actions on their behalf, they may be more likely to choose us again for their medical care,” says Zelazny.

A Growing Need to Consider Ethical Issues

Multiple forces and factors have emerged over the past few decades, contributing to ethical dilemmas, questions and concerns for nurses, other healthcare professionals, patients and their surrogate decision-makers. A few examples are:

• The development of innovative medical technologies, medications, interventions and diagnostics
• An emphasis on patient autonomy, wishes, preferences and goals
• As a corollary to patient autonomy, the importance of informed consent (and refusal) and advance directives
• The plurality of values and perspectives, especially for those with different cultural and religious backgrounds
• The increased acuity and complexity of hospitalized patients
• Concerns for resource utilization and allocation, and cost containment

The need for nurses to have knowledge, skills and resources to navigate the resulting clinical ethics issues effectively and successfully has never been greater.