Creating an Ethical Environment Where Courage Can Flourish

Kate Payne, RN, JDDirector of Ethics and Palliative Care

kpayne@stthomas.orgSaint Thomas Hospital

Nashville, TN 37205

Objectives

• Define and describe moral distress• Identify contributing factors and causes• Identify strategies to address moral distress

and develop moral courage• Describe why it matters

About the Law

• Protect Ethics/Reduce Liability– Identify and clarify the dilemma– Demonstrate good judgment– Communicate effectively– Facilitate negotiation– Improve decision-making

• Ethics is the ceiling, law is the floor

Ethics: Why?

• Decision making guided by ethical decision making processes

• Decision making informed by ethical values

• Decrease moral distress

What is Ethics?

• It can be about resolving dilemmas.• It can be about individual actions.• It is also about what kind of persons we are

becoming, our character and how our choices shape us.

• Ethics is ultimately about human flourishing, about living well, about achieving good through means that are consistent with real human values and needs.

What is Organizational Ethics?• It can be about compliance.• It can be about due diligence.• It can be about resolving value conflicts.• Organizational ethics is about.

– Integrity– Decisions/actions that are consistent with moral

identity and values of the organization– Helping the organization, its associates, and the

communities it serves truly flourish

Role of Ethics Mechanisms• Improve and enhance the quality of patient care

– Care of employees• Education

– Committee, staff, community• Administrative

– Policy development and review.– Oversight and comment on operations with ethical impact

• Consultation and case review– Conflict resolution

• Inform other institutional efforts– Regulatory compliance– Reduction of costs (without increasing mortality)

Ethics Experience• Elemental work: protect……..from harm• Social safeguard for potential harm • Examine differences• Recognize that conflicts are more • Awareness of values in play, conflicts of interest• Proper place of ethical theories • Ethics is a group activity• Unique decisions about individuals in relationship(s)

Principled Decision Making adapted from Robert Orr, MD

FAITH BASED

Sanctity of lifeCompassion

ServiceMeritorious sufferingRedemptive suffering

Contentment

MercyGraceHopeScriptureEternityRitualSocial justice

Respect for lifeTruth tellingNon-exploitationAdvocacyBenefit/burden

Free willObedience

StewardshipFaith

SovereigntyDominion

God’s purpose

DiagnosisPrognosis

Treatment options

ValuesGoalsWishes

SocialCultural

LegalFinancial

PhysicalPsychologicalSocialSpiritual

Patient Preferences

Contextual Features

Medical Indications

Quality

of Life

SECULAR

Non-Maleficence

BeneficenceJustice

Respect for Autonomy

Fidelity

ModelProfessional’s

ObligationNature of

RelationshipNature of

Health Care

Beneficent

Preventive

Covenant

Contractual

Business Commodity

Service

Obligation

Life-style

Negotiatedgood

Buyer/Seller

Sacred trust

Unilateraloption

Trust(fiduciary bond)

Contractingequals

Commitment,Skill

Commitment tolife

N/A

Act for good ofpatient

Supply specificservice

Health Care Models

Why Ethics?

• Need a moral compass to guide difficult decisions that have to be made in the health care context. N

S

W E

Moral Compass

Mission

Values

Ethics

Vision

Vision• Defining and achieving a desired future• Best hindsight and foresight for action• Possibilities• The best healthcare system• Your best life• Fat free chocolate

Mission• Mission makes us who we are

– It is our purpose

• Human beings are valuable– Because they are created by God– People are ends unto themselves

• Excellent practice, excellent care– Is where mission finds form and expression

Values• What is most important• Priorities• Worth• Value set

– Personal values– Professional values– Organizational values

Virtues/Values• Cardinal virtues

– Prudence, courage, temperance and justice

• Modern virtues– Unconditional positive regard, charity,

compassion, trustworthiness, vigilance and agility

• Other– Dedication, loyalty, honesty, creativity, faith,

family, care of the poor, competence, learning

Ethics

• Act in accordance with values based on universal principles

• External reflection of an internal moral code• Actions that enhance the well being of others

“So much for moral clarity.”

Ethical Dilemmas• Conflict between two ‘rights’• Principles, decision making frameworks, or tools help

clarify what is important• Ethics process

– ID areas of conflict– ID (other) resources– Provide support, understanding– Help move toward resolution

• Goal/hope: a 3rd way forward– Something besides two extremes

Ethical Components of Moral Distress

• Obligations of self• Obligations of others• Boundaries• Risks and benefits of action• Critical thinking/response

– Knowledge, skills, resources needed– Anticipation– Management– Action

Care Giving: A Moral Endeavor

• Roots of the caring professions• Promotion of ideal for patient care

– Respect for persons– Conduct by advocacy– Safe and best care

• Care giver role/relationship– Fundamentally ethical– Care giver role/relationship is complex

• Patient/client focused caring• Some distress is unavoidable

• “Painful feelings and/or the psychological disequilibrium that occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”– Jameton A.

• Nursing Practice: The Ethical Issues. NJ:Prentiss-Hall. 1984

Moral Distress Defined…

…defined

• 1993 Jameton distinguished:– Initial: frustration, anger and anxiety due to

• Institutional obstacles• Interpersonal conflict about values

– Reactive: due to failure to address initial distress• 2000 Webster and Baylis included

– Failure to pursue “right” course of action due to• Error in judgment• Personal failing• Circumstances beyond control

– May feel cherished beliefs violated • Compromised integrity

• “..the pain or anguish affecting the mind, body or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; yet as a result of real or perceived constraints, participates in perceived moral wrongdoing.” – Alvita Nathaniel MSN, RNCS

• In Nursing World, July 28, 2002

….defined

Other/Related Distress…

• Jading– A process leading to exhaustion from being overdriven to

perform long, continued labor and/or severe or tedious tasks.

• Burn out– Individual or group stress related to one’s relationship

with the work environment

• Grief out– Repeated, sustained and often unresolved grief and loss

…distress• Compassion fatigue

– Gradual lessening, over time of ability to be compassionate.

– The price one pays for caring.– Emotional stress experienced from exposure to the

suffering of others.• Secondary Traumatic Stress (STS)

– Presence of Post-Traumatic Stress Disorder (PTSD) in the caregiver.

• Both STS and CF are caused by exposure to patients who have been traumatized or are suffering, not to the traumatic event itself.– Vicarious traumatization

Personal• Psychological/emotional• Closeness/identification with patient/client• Boundaries• Isolation• Feelings of powerlessness or helplessness• Compromise of one’s standards of care• Feelings of failure or guilt

– Inability to talk about it• Grief and loss

– Lack of time to process– Accumulated grief and loss– Lack of closure

• Sustained proximity contributes to sense of responsibility

Professional Barriers• Staffing

– So low, care is inadequate– Lack of time, skill– Novice staff– Multiple deaths in close

succession – High patient/client acuity

• Organizational change– Quality, safety– Cost cutting: Doing more

with less

• Leadership dynamics• Nature of relationships

– Closeness/Identification– Patient and/or family

issues• Effectiveness of team

– Power imbalance – Lack of collaboration

….professional• Role/Relevance questions

– Limited role in decision making– Belief that decisions contradict best interests– Confusion about plan– Too many partners or consultants

• Communication failures– In team, between teams– Patient or family

• Sustained proximity when others walk away• Technological imperative/futility

– Doing everything vs. the right thing• Belief “doing everything” a sign of faithfulness

– Death a failure• Discomfort with own mortality

….professional

• Conflict– Assertive/aggressive patients/clients

and families– Intra or interdisciplinary conflict

• Outside pressures – Organizational, professional, personal

• Economy• Pandemic• Politics

Symptoms of Moral Distress

• Emotional/psychological– Intrusive thoughts – Disturbing dreams– Sense of reliving trauma– Cued psychological distress

• Difficulty concentrating• Hypervigilance• Anxiety• Frustration• Depression

….symptoms

• Irritability, anger, insults, blaming• Physical

– Cued physiological reaction– Fatigue– Somatic concerns– Diminished activity level– Difficulty sleeping

• Feelings of inadequacy– Personal, professional – Feeling victimized

….symptoms• Distancing oneself

– Detachment from others– Avoidance of others, places, activities

• Absenteeism– Emotional numbing – Foreshortened future

• Poor or inappropriate care– Inability to recall patient/client information

• Loss of integrity and authenticity• Loss of meaning• Crisis of faith

Organizational Barriers• Hospitals/other settings

– Cure orientation – Death as failure– Biomedical focus– Technology– Lack of time– Failure of team

• Leadership dynamics• Lack of collaboration• Conflict

– Patient/client with sudden, critical illness• Wishes unknown

• Sustained proximity when others walk away

Organizational Inhibitors• Culture(s) that

– Stifle discussion regarding unethical behaviors and/or tolerate unethical acts

– Willing to compromise personal and professional standards

• to avoid social isolation from peers • to secure a promotion/favoritism within the organization

– Group think to turn the other way – Unwillingness to face the tough challenge of addressing

unethical behaviors– Redefine unethical behaviors as acceptable– Indifference to ethical values– Apathy of bystanders

Work Place Culture

• Pathologic culture• Bureaucratic culture• Generative culture

– Components• Informed/informing• Just• Flexible• Learning

• What does your culture look like?

Organization Symptoms• Depression, psychosis screening

– Hopeless about the future– Difficulty making decisions– Loss of interest– Agitation– Feeling trapped– Negative vision, risk-avoidance, downplay threats– Lack of care, cause harm

Crescendo EffectSolid lines indicate moral distressDotted lines indicate moral residue

Moral Distress

TimeMoral residue crescendo

Moral residue

Moral distresscrescendo

Strategies to Address Moral Distress…

• Causal analysis• Self awareness/self

monitoring– Limits, issues

• Address issues in real time– Debriefing

• “Talk about it”– Ethical dialog

• Referral• Skill-building

• Grief work• Engage in work of

“letting go”– At the bedside– Funerals, journal, phone

calls– Sacred/holy

….strategies• Story telling• Self-care

– Balance• Appropriate boundaries

– Spiritual practice• Find own voice/advocacy

– Courage• Develop sources of support

– Professional– Referral sources– Social– Play

“Hard to tell from here. Could be buzzards. Could be grief counselors.”

Organization “Prozac”?

• Insight-top down• Shock therapy• Organizational soul• Admit there is a problem• Re-inspire• Re-invigorate• Re-energize• Re-discover roots

Self esteem/self confidence

Accountability, self-control, and resilience

Professionalism/self-development/respect and rational decision making

Customer service, patient rights, communication, and teamwork

Organizational awareness, performance improvement,

information management

Cost control, safety, infection control,

facility, others

Decker PJ. The Hidden Competencies of Healthcare: Why Self-Esteem, Accountability, and Professionalism May Affect Hospital Customer Satisfaction Scores. Hospital Topics. 1999;77:14-26 (1999).

Resources to Address Moral Distress

• Opportunities for breaks

• Places of “sanctuary”• Real time interventions

– One on one– Huddles– Rituals of letting go

• Consults– Internal, external

• Support Groups• CISM• Other forums

– Rounds, grand rounds– Round table, journal club– Schwartz Center Rounds

Ethics Resources

• Mission, Vision, Values• Code of Ethics• Ethics Consultation, Ethics Committee• Organization Ethics Committee• Compliance• Conflict of Interest Committee• Institutional Review Board

…ethics resources

• Pastoral care• Palliative care• Employee Assistance Program• Patient advocate• Quality improvement• Outcomes management• Patient safety• Risk management

Interventions• Ethics mechanisms• Round table• Grand rounds• Facilitated ethics conversations• Follow up education after consultation• Curbside conflict management• Mediation• Informal, curbside education• Monthly brown bags

Healing Teams

• Interdisciplinary/collaborative– Role modeling– Mentoring– Skill building/capacity– Education

• Conversation– Affirmation of positive– Encouraging when

negative

• Blessing• Flexible and creative• Trusting environment

– Safe place to talk

• Bereavement• Effective leadership

Effective Organizations• Recurring and systemic causes identified and monitored

– Correct the problem– Targeted interventions

• Adequate financial and people resources– Ethics resources– Palliative care– Conflict resolution– Interdisciplinary forums to discuss complex “situations”

• Mechanisms to address issues• Accountability for practice and behavior• Skill building, education, mentoring• Bereavement mechanism

– Where death is frequent

Community Resources

• Grief counseling (through hospice, other)• Agencies• Crisis lines/centers• Counselors, therapists• Clergy in the community• Who/what have you found helpful?

Leadership Responsibility

• Take bold steps to engage interdisciplinary colleagues to create solutions, monitor progress

• Develop and implement targeted strategies and evaluate their effectiveness– Involve medicine, nursing, social work, pastoral care,

ethics consultants, mental health professionals, palliative care, and other disciplines that have relevant expertise

• Recognize the symptoms of distress and create opportunities to explore the behaviors and coping strategies

…leadership

• Communication forums, modeling of good communication

• Engage in systematic review of cases• Develop and use support systems• Build a trustworthy community, with rewards and

recognition, development of strategies for resilience, self-care, renewal, and personal growth

• Reach out to community• Leverage resources and relationships