fnfasiw and Cnfd Can Nursing (1993) 9, 191-194

@ Longman Group UK L:d 1993

The role of the nurse in ethical decision-making in intensive care units

Christine Watson

This paper focuses on the nurses’ role in ethical decision-making in intensive care units (ICUs) of hospitals in the UK. There is a paucity of research on the topic, studies published are generally North American or Canadian in origin. The available literature suggests that although nurses are constantly at the intensive care patient’s bedside, often making complex decisions about treatment and care, their involvement in ethical decision-making is limited. This paper provides a review of the literature on how ethical decisions are made and the influences on nurses’ participation in this process.

INTRODUCTION

Advances in technology and drug therapy mean that life can be extended and preserved for many critically ill people who, in past years, would have no hope of survival (Young 1988). When a patient’s condition becomes irrecover- able, however, rather than sustaining life, treat- ment may only be prolonging death. At this stage once competent patients may now be too ill to make decisions and others must assume that responsibility for them. Ethical decisions, par- ticularly those involving withholding or with- drawing treatment, are therefore made on a regular basis in ICUs.

The organisation of nursing care in these specialised units, often puts nurses in a unique position to contribute to this decision-making

Christine Watson RGN, ENB 100, BN(Hons), Lecturer in Nursing, University of the West of England, Bristol BS16 2JP, UK

(Requests for offprints to CW)

Manuscript accepted 17 March 7993

LC.N.- C

process. There is a high nurse:patient ratio. One nurse may provide life-sustaining care, hour after hour, day after day, often forming a close relationship with both the patient and his or her family (Wlody 1990). This constant interaction allows opportunity to discuss the wishes of the individuals involved regarding the treatment regimen and their thoughts about death and dying. The nurse, therefore, may be the most appropriate person to facilitate the patient or family’s participation in ethical decision-making, or represent their views if they are unable or unwilling to participate. Indeed, nurses are required by their Professional Code of Conduct to assume an advocacy role, to ‘promote and safeguard the well-being of the patient’ (UKCC 1992).

Although nurses are apparently well-placed to facilitate patient-centred decisions, the available evidence suggests that this role is not fulfilled. Holly (1989), studied 45 critical care nurses’ participation in ethical decision-making in rela- tion to perceptions of environmental social support. She found that there were limited roles for patient, family or nurse participation in

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192 INTENSIVE AND CRITICAL CARE NURSING

ethical decision-making and when nurses were

involved, they were only supported by other nurses. 75% of the nurses surveyed reported

that ethical decisions were made by doctors.

Although the small study sample makes findings

difficult to generalise, the study suggests that

nurses lack the support and freedom to engage

in ethical decision-making or to act in an advo-

cacy role in such a situation.

That this inability to participate in ethical

decisions is preventing nurses from assuming

the patient advocate role is supported by the

findings of Rodney (1988) and expanded upon

by Fenton (1988), who found that lack of partici- pation causes feelings of anger, frustration and

powerlessness. That nurses lack autonomy

within the health care team is not a new proposi- tion. In 1967 Stein described a stereotypic com-

munication pattern he called the ‘doctor-nurse

game’. In order to appear passive, the nurse gave recommendations about patient care in such a

way that they appeared to be initiated by the doctor. In a recent re-evaluation of the doctor-

nurse game, Stein et al (1990) assert that little has

changed and that in many places the game is

played as first described.

It is doubtful, however, if this phenomenon is

wholly applicable to the nurse-doctor relation-

ship in ICUs. Critical care areas often require

that nurses make rapid decisions under crisis

situations when there has been a rapid change in

the patient’s condition (Baumann & Bourbon- nais 1982). Immediate action may be required in

these situations and decisions cannot be post-

poned to await consultation with medical staff.

This need to make rapid decisions based on

sound rationale may be what differentiates the

role of critical care nurses from their colleagues in less acute areas. Holly (1989) reports that critical care nurses are more assertive and func- tion more autonomously than most. If this is so, why does the available evidence suggest that these nurses do not participate in ethical deci- sion-making?

It may be helpful here to examine what constitutes an ethical decision and what approach will enable a satisfactory resolution of an ethical dilemma. According to Benjamin &

‘the application of various skills of ethical

analysis and reasoning in an attempt to reach a well-grounded solution to an ethical problem’.

It is difficult to determine British intensive

care nurses’ level of skill in ethical analysis and

moral reasoning due to the lack of available

research. In their integrative review of Ameri-

can research in this area, Ketefian & Ormond

(1988) state that the relationship between edu- cation and moral reasoning remains ambiguous,

mainly due to research design limitations.

However, educational preparation of nurses

may give an indication of present practice.

Curriculum content varies from college to

college and on examination of course documen-

tation (Bristol Polytechnic 1987, Leeds College

of Nursing 1991, Avon College of Health 1990

etc.) although ethics are taught in both pre-regis-

tration programmes and post-registration

intensive care courses, the development of prac-

tical skills in ethical analysis is not addressed.

Two current approaches to moral education in nursing curricula, namely, putting ethics into

the same context as a study of professional codes

of conduct and imparting moral theories as the

basis for action, are strongly rejected by van Hooft (1990). He argues for a process he calls

‘empowerment’ which develops nurses’ conli-

dence and sensitivity in the making of difficult

decisions, by attitudinal change and reflective

practice. While this seems a commendable

approach, it is difficult to see how ‘well-groun-

ded’ decisions (Benjamin & Curtis 1986), can be

made without the study of ethical theory. A combination of teaching methods, including the

study of ethical theory and empowerment, may

facilitate nurses’ participation in the ethical deci- sion-making process.

What actually happens during this process is difficult to determine due to the lack of research in the area. There are, however, several models available which propose a structure for resolving

ethical dilemmas. One such model, Curtin (1992), is particularly succinct and is therefore readily applied to critical care situations, where time may inhibit lengthy deliberation. The model is summarised below:

Curtis (1986), ethical decision-making is 1. Background information. Information is

INTENSIVE AND CRITICAL CARE NURSING 1%

2.

3.

4.

5.

6.

gathered, organised and ranked in order

of relevance of the decision to be made,

thus determining the problem(s). Identification of ethical component. The

problem is analysed to see if it fits the

definition of an ethical problem. It is then analysed in terms of ethical theory to

determine moral rights, duties, obligations

and principles involved. Identification of individuals to be involved.

All people involved in the decision, their

level of competence and how they are involved is identified. Lines of authority

and resonsibility should be clarified. Con-

flicting human rights must be identified

and ranked. Identify options. Alternative courses of

action are identified, with the consequen-

ces for each projected.

Reconciling facts and principles. Alterna-

tives are examined in terms of values and ethical theory.

Resolution. An attempt is made to achieve

consensus of all parties involved. Curtin (1982) states that legal requirements and

social expectations may influence the deci-

sion but should not dictate it.

As previously mentioned there is no evidence

to suggest that this type of approach, or indeed

any formal structure is used in this country to aid

ethical decision-making. However, the model

does illustrate the complexity of the decision-

making process and it could be postulated that it

is nurses’ lack of educational preparation which

is an inhibiting factor to their involvement in

such processes.

According to Grundstein-Amado (1992), nur-

ses’ participation in ethical decision-making would humanise the process. She found that

nurses placed the highest value on the ‘caring’ perspective, which entails sensitivity to the patients’ wishes. In contrast, doctors value patients’ rights and a scientific approach con-

cerned with disease and its cure. Although again this study sample was small (n = 18) making findings difficult to generalise, sociological

research in nursing substantiates the idea that the two professions act from different points of

reference (Salvage 1985, Bush & Kjervik 1979,

Melia 198 1). A joint approach, based on mutual

participation by doctors and nurses, may enable a more balanced resolution of these difficult dilemmas.

To conclude, although nurses are constantly

at the patients’ bedside, often making complex

decisions about treatment and care in ICUs, the

available evidence suggests that their involve- ment in ethical decision-making is limited.

Traditionally, doctors appear to have pro-

fessional dominance over nurses and thus some

nurses are socialised into passive roles. Nurses’

lack of educational preparation in the areas of

moral reasoning and ethical practice may be a

further inhibitant to their participation in what

appears to be a complex cognitive process.

However, the suggestion is that nurses desire

involvement in ethical decision-making and

their professional code requires this of them.

Furthermore, their caring perspective may facilitate a more patient-centred approach to the

resolution of ethical problems.

References

Avon College of Health 1990 Unpublished Project 2000 curriculum

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Benjamin M and Curtis J 1986 Ethics in nursing, 2nd edn. Oxford University Press, New York ..

Bristol Polvtechnic 1988 Unnublished BSc (Hans) Nursing’with RGN, tours; curriculum document

Bush M A and Kjervik D K 1979 Women in stress - a nursing perspective. Appleton-Century-Croft, New York

Curtin L 1982 No rush to judgement. In: Curtin L and Flaherty M J (eds) Nursing ethics theories and pragmatics. Robert J Brady Co, Maryland, pp 57-63

Fenton M J 1988 Moral distress in clinical practice: implications for the nurse administrator. Canadian Journal of Nurse Administration 1 (10): 8-l 1

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