Coping with ICU Ethics

[EMSnut45, BSN, RN, EMT-P]

I'm a new grad (6 months in) in a MICU at a large teaching hospital. I feel that I have a pretty good grasp on nursing procedures and time management, and have now run into a "brick wall" with ethics. I find myself in constant inner turmoil over the amount of procedures/tubes/wires/drips/etc that we do to patients who so obviously are not going to overcome their illness. I've had patients who beg and plead to be extubated, have living wills to support it, and the docs just won't stop. The common thread is that the docs have one story that they tell during rounds (this is futile), and then turn right around and tell the family that they have every reason to believe that they'll pull through. They talk out of both sides of their mouths, and meanwhile, I'm left caring for a patient who is suffering, and a family who is confused.

I've had family request to withdrawl agressive measures, and when I tell the docs, I get "we're not done with them yet" in response. I feel like my patients are guinea pigs, and are denied a death with dignity.

I have gone to my peers and supervisor, but have not found any advice on how to cope.

I love being a nurse. I love the ICU. I love being able to help the patients and their family in their most vulnerable state. I just hate seeing the patients suffer and be kept alive artifically for so long because the interns and residents need learning experiences. Where is the humanity in that?

Do you have any suggestions on how I can get over this? Are there any resources (books, articles, etc) that might point me in the right direction?

[tri-rn]

I feel the same way, and I wish I had an answer, but I don't...I lose a lot of sleep over this stuff and I think eventually I'll have to get out of the ICU.

All you can do is what it sounds like what you're already doing...advocate for your patients. You and I didn't create the system...we can't change the entire system...all we can do is work within it the best we can:banghead:

[TemperStripe]

We get this all the time, especially in surgery. Read the book "The Final Exam" to get a better understanding of how doctors tick, and how they are taught, from Day 1 of medical school, that death is personal failure in all circumstances. It is very unfortunate but I also feel they are generally still doing what they believe is "right," it's just that we all have a different definition of "right." There's no easy way around it in a lot of cases. It does help to know how to ask for what you want in a way that you will get it...this takes time, I am still learning. Never stop advocating.

[NotReady4PrimeTime, RN]

What you're feeling is called moral distress. It's a very common phenomenon in ICUs, especially for nurses. It's the nurse who spends large chunks of time with these patients and their families, it's the nurse who hears the pleas, it's the nurse who sees and acknowledges the suffering, but it's not the nurse who has the authority to make the decisions. Moral distress is a recognized issue and there is a great deal of research into the causes and solutions. Here are some links to articles that will help you understand why you're feeling what you're feeling and offer some suggestions for coping.

Facilitated Ethics Conversations: A Novel Program for Managing Moral Distress in Bedside Nursing Staff

Moral Distress: Recognizing it to Retain Nurses: Relieving Moral Distress

The Cost of Dying - 60 Minutes - CBS News

I have other references but they're all pediatric in focus.

[getoverit, BSN, RN, EMT-P]

Welcome to ICU nursing, I think most everyone has this same moral distress. I have definitely experienced it many times, seems to happen with some doctors more than others.

Some have suggested books and websites, which are all good. Talking about it with your co-workers can help alleviate stress too.

I assume your hospital has an Ethics Committee? You should consider joining it, then you can participate in a more in-depth discussion about it. Part of our Ethics committee involves a Palliative Care committee. they meet almost everyday and discuss any patient that the nursing staff deems "appropriate". sometimes physicians disagree but we've been able to avoid some of the problems you listed once our palliative nursing team gets involved.

[EMSnut45, BSN, RN, EMT-P]

Caroline-- Thanks for the book suggestion! I'll see if I can put my hands on a copy.

Jan-- Those articles were great! I had heard that 60 minutes did a series, but didn't watch them. I'm looking forward to watching them from your link when I get some time this week.

I went back to the nurse who was my preceptor, and found out that she also struggles with the ethical stuff too (and she has been a nurse for 10 years in multiple ICU's throughout the country). It was a nice chat, and I definately feel better after talking with her and finding out that I'm not alone. I also let our palliative care nurse know that I'm having difficulties, and she is going to try to get some literature for me as well. I initially felt like I was the "only" one feeling this way, so it brings comfort knowing that I'm not alone.

It also helps that I cared for two very determined and sweet patients over the past two days. Both of them will get over this "bump" in their road, and recover nicely (without causing me moral distress :) ). One of them was alert and oriented x3, had been intubated for quite some time, and was missing the world beyond the 4 walls of her room. The window in her room was behind her, and I was able to turn her bed around for a few hours so that she could look outside and see it snow. It made my heart turn to mush as she started to cry and thanked me! Oh, the little joys in nursing... I'm learning to savor them!

Thank you all for your replies!!

[NotReady4PrimeTime, RN]

Now that's taking care of your own spirit! It always feels so good to be able to do something so simple that means so much. A while back we had a patient who was not going to survive and everybody knew it. The family wasn't quite ready to let go, but they knew it was eventually not going to be a choice. The last night the patient was with us, we were able to get them all into bed together for the only time in the patient's brief life. It was worth every difficulty we had making it happen. And that kind of thing will keep me going for a while.

[Dinith88]

I disagree with those who are posting "...well...thats just life in the ICU....". I understand where they're coming from, in that we're constantly...daily...exposed to all this suffering and death and tragedy...and...

BUT...from your post you mention that these hopeless cases are kept going/suffering for the sake of learning? And despite patient and/or family wishes the doctors (and 'baby-doctors') boldy lie to families and disregard their wishes??? Really?

If you are indeed suffering from such an authentic moral dilemma, you will be complicit in this immoral activity and completely ignoring your moral 'duty' to these patients IF you don't attempt to change it.

Maybe it's because you're a new nurse and not yet entirely comfortable in dealing with doctors...but if you call them out on this...repeatedly...and in front of others...the activity will likely change...you dont need to yell or be angry...(this is just one simple 'way' of changing bad doctor behavior)

And never forget you're the patient's/family's agent in these cases.

It's a shame you work with such cold-hearted jack-A$$es....and it's a shame that you feel powerless to attempt to change this behavior because of the "doctor-god" culture of healthcare...

I hope, in your nursing practice, you reach a point where you have the moral 'fortitude' to act rather than simply wax-poetic about this suffering and injustice. Until then, your moral angst will be firmly strapped to your back...and it should be.

[geekgolightly, BSN, RN]

I work in a hospital where there is not a residency in critical care and have not experienced moral distress related to doctors not wanting to give up, only from families not wanting to give up. That's pretty hard to take, as well, when you know it's futile care. Last big example was ov ca with mets to brain, liver and lungs. Intubated, on multiple pressors, TPA r/t not being able to tolerate feeds, Stage IV decubiti, no sedation as family did not want her sedated. She was with us for almost five months in the ICU until her death. Her stay was not pretty. It was pain filled and awful to watch. Her husband would not let go and threatened us with a lawsuit if we even breathed a word about end-of-life issues.

Our intensivists and hospitalist docs, though, are very reasonable and quick to respond to any patient/POA who wishes to stop heroic measures, and are good about consulting palliative care and bringing up end-of-life issues appropriately.

Do you think it's because of the residency program in place that your docs are having a hard time letting go of the really sick ones? Because the truly critically ill are certainly a learning experience.

In any case, I think as a previous poster suggested, it might be a good idea to join the ethics committee to lend your perspective and drive to help change this practice.