Moral distress

Q Maintaining my moral integrity is important to me, yet I have been faced with situations that challenge my ethical compass. How do I develop the internal strength to remain true to my values? How can my organization support efforts by my coworkers and me to speak up when we feel there are ethical concerns? What can I do as an individual and what can my organization do to enhance the environment to ensure ethical practice?A Karen Stutzer, rn, phd, and Mary Bylone, rn, msm, cnml, reply:It is well documented and acknowledged that the critical care environment contains daily challenges to individual nurses in regard to their moral integrity.1–3 Andrew Jameton4 initially described moral distress as when "one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action."4(p6) Identifying moral distress was the beginning of decades of work that has described and measured the impact of moral distress across multiple nursing specialties.1 The debilitating impact of moral distress on nurses is supported by research and includes burnout, disengagement from patients and families, stress-related illnesses, turnover, and leaving the profession.1A promising approach to addressing situations that challenge one's ethical compass and the resulting moral distress is to incorporate strategies that promote moral resilience into organizational and individual practices. Moral resilience has been described as "the capacity of an individual to sustain or restore integrity in response to moral complexity, confusion, distress or setbacks."5(pS13) Developing personal strategies to strengthen one's approach to ethically distressing situations and seeking organizational strategies to support ethical practice are 2 ways to build moral resilience capacity.At the National Teaching Institute held in May 2017, a panel led several hundred acute and critical care nurses in a discussion about moral distress. Participants were encouraged to "forge a new path"6 and consider strategies to shift the dialogue and experience to those that promote resilience. This column is a reflection of the thinking of these participant experts—acute and critical care nurses who navigate the health care system to advocate for patients and families daily (Tables 1 and 2).Care for the critically ill patients occurs within health care organizations, and the ethical climate of those environments directly affects the ability of the nurse and members of the interprofessional team to provide care ethically.8 Health care organizations can and should provide systemic support to ensure the environment is conducive to ethical practice. The American Nurses Association Code of Ethics requires nursing leaders, in collaboration with nursing care providers, to ensure the practice environment supports the moral integrity of nurses.9,10Policies that support ethical practice are key to creating organizational infrastructure that can mitigate morally distressing events. Nursing leadership and bedside care providers need to identify the policies that are most supportive of ethical practice and develop those policies collaboratively. Among the areas that might be covered are mechanisms for addressing ethical concerns, protection of moral integrity, and organizational priorities for ethical practice. More specific examples include informed consent, withholding and withdrawal of life-sustaining therapies, health care decision-making, and calling an ethics consultation.11Nursing leaders are positioned to influence ethical practice through their words and deeds. Through support of shared governance structures, nurses are able to ensure their voice is included in policy development. It is key that policies and practice reinforce the expectation that nurses will verbalize concerns.12Organizations must provide adequate financial and human resources to support an ethical culture. The presence of effective ethics committees and qualified ethics consultants provides organizational structure for ethical practice.8 There should also be support for nurses who provide care to patients to be part of these committees. Organizations should provide processes, structures, and well-prepared educators to ensure ongoing education to develop and sustain ethical competence. Inquiring daily about potential ethical concerns in concert with the presence of well-prepared ethics resources can provide opportunity for early intervention and perhaps diminish the degree of distress experienced by all members of the team.13The emergence of moral resilience as a strategy to manage and cope with moral distress is a relatively new discussion. As one thinks about personal actions, it is an important step to recognize one's intrinsic ability to care for oneself, advocate for patients, and work with organizational leadership to address ethically distressing situations. The professional Code of Ethics supports the requirement that nurses must promote personal health and well-being, and advocate for patients and ethical work environments.9Moral resilience comes from a place of intentional actions to build on personal strengths. Knowing one's personal values and being willing to take courageous action move the experience from one of distress to one of resilience.5 The ability to stay true to oneself, make decisions that are consistent with one's beliefs, and persevere in addressing concerns are attributes of moral resilience12 and behaviors one can develop and nurture. Additionally, nurses must be willing to support others in these situations, even when the issue is not a problem for themselves. Knowing your colleagues are supportive of what is important to you provides strength for speaking up, which, in turn, improves the dialogue.Maintaining balance and harmony in one's life needs to be a priority. A healthy diet, proper rest, and time for relaxation can foster the needed energy to cope with distressing situations. Mindfulness practices, exercise, yoga, or other activities that encourage respite from stress can also enhance resilience.Membership in professional organizations should be considered a strategy to promoting moral resilience. Nursing organizations provide a collective voice for nursing concerns and issues, and provide opportunities for networking and supportive dialogue with colleagues. The American Nurses Association has convened a professional issues panel that examines moral resilience with the intention of identifying strategies to strengthen the ethical voice of nurses and, thereby, promote moral resilience.14 In addition to the development and publication of the Healthy Work Environment Standards,7 the American Association of Critical-Care Nurses is an active participant in collaborating with a variety of nursing organizations to promote moral resilience.3 More work is needed to make these documents part of every workplace.Moral resilience moves the internal dialogue from one of disappointment and powerlessness to one of strength and empowerment. Consciously acting to develop moral resilience enhances one's self-confidence in managing ethically difficult situations.12 Through an ongoing commitment to developing self-awareness and insight when faced with ethical challenges, one can gain a deeper sense of understanding and sense of mastery when faced with ethically distressing situations.5

BackgroundCaesarean section on maternal request (CSMR) raises ethical and clinical challenges despite Sweden’s low overall caesarean section (CS) rate. National written recommendations are restrictive, yet regional differences suggest unequal care. While previous research has focused on women and healthcare professionals, little is known about the views on CSMR of policymakers and other key stakeholders. The aim of this study was to investigate how stakeholders in the Swedish healthcare system view CSMR in relation to medical considerations, individual autonomy and societal values.MethodsA qualitative study with an inductive approach was conducted using reflexive thematic analysis of semi-structured interviews. Sixteen stakeholders were recruited, including regional politicians, policymakers, national authority representatives, and members from organisations and associations with relevant interest and expertise in the field.ResultsFive themes were generated: (1) Caesarean section is a valid way of giving birth for some; (2) The right to choose and the decision process are complex issues; (3) Individual options for childbirth are desirable; (4) There is a lack of trust in maternity care; (5) Economic and ethical challenges in maternity care exist. The participants viewed CSMR as a legitimate option for some women, despite the increased medical risks, which were considered concerning but not disqualifying. Support and guidance in decision-making were considered essential by the participants. They valued continuity in care and emotional support highly. The participants expressed the views that distrust in Swedish maternity care was linked to media portrayals and inconsistent handling of CSMR. Economic and ethical concerns included questions of resource allocation and the scope of public healthcare responsibilities. The option to pay privately for a planned CS was broadly rejected by the participants.ConclusionsThis study highlights the complexity of CSMR and its varied perspectives. While individual risks may be low, population-level risks could rise with increased prevalence, and the perception of risk varies depending on perspective. Both medical and psychological risks should inform decisions, with counselling seen as crucial by the participants. Continuity of midwife care models may offer an alternative to CSMR for some. Stakeholders are key to ensuring clear guidelines, equal care, and trust in the system.

Background: The increase in chronic diseases, dealing with a diverse clientele, the rapidly developing digitalization in healthcare as well as the demand for interprofessionalism poses complex demands on the midwifery as profession. Within this context institutions of higher education are expected to train midwives as trendsetters in the development of new, integrated healthcare models which can meet the health needs of mothers and their families. Goal: The goal of the master course in midwifery is to increase awareness of the relevance of current challenges in maternity care. Midwives are prepared to competently deal with current health issues, using innovative healthcare models, by taking on advanced and specialized roles. Methods: The course imparts knowledge and know-how for midwives who wish to prepare to take on duties in modern obstetric and maternity care. Midwifery master students complete interprofessional course modules, such as Ethics, Advanced Practice or Health Policy and Health Economics, conjointly with fellow students of nursing, physiotherapy as well as nutrition and dietetics degrees. Three profession-specific course modules focus on the challenges imposed by complex processes in perinatal care. Results: The case study of a 5th semester student shows how the course supports the development of the new role of an Advanced Practice Midwife (APM) in the field of perinatal mental health. As an assignment within the profession-specific course module Perinatal Mental Health the student developed a concept draft for an APM role. She presented the concept in her own field of work, where she was charged with further developing and advancing the project. Furthermore, the student focused her Transfer Course modules on the project and deepened her skills in mental health and research skills through work shadowing in a research department and mental health ward, also called ,,Crisis lntervention Centre", in a university psychiatric clinic. Based on the APN model she finally developed how to establish the APM role in her master thesis. To conduct the needs assessment for mentally ill pregnant women and mothers she is conducting a secondary data analysis of a research project of the Division of Midwifery of BFH. Relevance: The establishment of integrated and intersectoral healthcare models is currently being discussed in Switzerland. The models require specific skills in healthcare professionals. The interprofessionally oriented master studies at BFH teach midwives to meet the requirements of needs-based, family-centred perinatal healthcare and strengthen its quality. Recommendations/Conclusions: The interlocking of master studies and practice offers the unique opportunity to further develop innovative healthcare models which are aimed at addressing present and future challenges in healthcare delivery and which are based on research.

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

Moral distress has emerged as a significant concern for critical care nurses, particularly due to the complex and demanding care provided to critically ill patients in critical care units. The ongoing COVID-19 pandemic has introduced new ethical challenges and changes in clinical practice, further exacerbating the experience of moral distress among these nurses. This systematic review compares the factors influencing moral distress among critical care nurses before and during the COVID-19 pandemic to gain a comprehensive understanding of the impact of the pandemic on moral distress. For this systematic review, PubMed, Scopus, ProQuest, Web of Science, medRxiv, bioRxiv, Embase, and Google Scholar were all utilized in the search. The search covered articles published from 2012 to December 2022, encompassing a 10-year timeframe to capture relevant research on moral distress among critical care nurses. In total, 52 articles were included in this systematic review. The findings indicate that personal, caring-related, and organizational factors can influence nurses' moral distress. Before the pandemic, factors including futile and end-of-life care, conflicts with physicians, nurse performance and authority, poor teamwork, decision-making regarding treatment processes and patient care, limited human resources and equipment, medical errors, patient restraints, and nurses' age and work experience affect critical care nurses' moral distress. Similarly, during the COVID-19 pandemic, factors contributing to moral distress include futile and end-of-life care, fear of contracting and spreading COVID-19, decision-making about treatment processes, poor teamwork, and being female. This study revealed that the factors contributing to moral distress were approximately similar in both periods. Futile care and end-of-life issues were critical care nurses' primary causes of moral distress. Implementing prevention strategies and reducing these underlying factors could decrease this major issue and improve the quality of care.

How physicians and scientists can respond responsibly and effectively to religiously based opposition to human embryonic stem cell research

This important book makes the case for placing maternity care in the community. It has been written by a multidisciplinary group. The first section considers the role and function of the participants in community-based maternity care; the woman, the midwife, and the GP. The second section discusses four major contemporary issues: the radically changing social background, the economics of care, audit, and education of the carers. Next the major clinical challenges in maternity care are tackled: how to reduce the differences in morbidity and mortality which are associated with differences in age, social class and ethnicity; the care of disadvantaged groups; prematurity and low birth weight and their prevention; technology used in childbirth; and the fetal origins of adult disease. Finally, all aspects of the clinical care carried out by Gps and midwives are covered. The editors hope that after reading this book midwives, Gps, and obstetricians should find the theory underpinning their work has been sharply defined and that their work will be more effective and evidence-based. The editors, a GP and a midwife, anticipate the resolution of the current tensions between midwife, GP, and obstetrician and look forward to a responsive, effective and sensitive service for mothers and babies in the next millennium.

Evidence-Based Review and Discussion Points

BackgroundMoral distress is reported to be a critical force contributing to intensifying rates of anxiety, depression and burnout experienced by healthcare workers. In this paper, we examine the moral dilemmas and ensuing distress personally and collectively experienced by healthcare workers while caring for patients during the pandemic.MethodsData are drawn from free-text responses from a cross-sectional national online survey of Australian healthcare workers about the patient care challenges they faced.ResultsThree themes were derived from qualitative content analysis that illuminated the ways in which moral dilemmas and distress were relationally experienced by healthcare workers: (1) the moral ambiguity of how to care well for patients amid a rapidly changing work environment; (2) the distress of witnessing suffering shared between healthcare workers and patients; and (3) the distress of performing new forms of invisible work in the absence of institutional recognition. These findings reveal that moral distress was a strongly shared experience.ConclusionsFindings advance understandings of moral distress as a relational experience, collectively felt, constituted, and experienced by healthcare workers. Considering how to harness collective solidarity in effectively responding to moral distress experienced across the frontline healthcare workforce is critical.

BackgroundMoral distress is the experience of knowing what ethically right action to take, but being unable to act accordingly, due to external factors. It is an experience common to providers working in the neonatal intensive care unit (NICU) where care for infants, often born at the edges of viability or with other life-limiting diagnoses, includes life and death medical decision-making in the context of uncertain prognoses. Palliative care, which aims to reduce suffering, can assist with staff moral distress by providing space for conversations regarding goals-of-care and end-of-life decision making.MethodsThe palliative care and NICU teams co-developed a weekly, case-based conference to discuss palliative care domains of high-risk newborns including pain and symptom management, goals of care, spiritual support, and psychosocial strengths and challenges. The Moral Distress Thermometer (MDT) and the Moral Distress Scale-Revised (MDS-R) were collected at baseline and at 6- and 12-months post-intervention implementation. Quantitative and qualitative analyses were employed as appropriate.ResultsOne-hundred thirty-seven participants completed both surveys at baseline including 46 physician/advanced practice providers (MD/APPs) and 91 registered nurses/other health professionals (RN/OHPs). There were statistically significant improvements in both the mean MDT scores and the mean MDS-R for the overall cohort and specifically for the RN/OHP group from baseline to 12-months post-intervention. There was a trend towards improvement on these measures among the MD/APP cohort. Qualitative analysis of the free-text responses revealed several themes describing moral distress in the NICU. Themes common to both groups included: futile/non-beneficial care, prognostic uncertainty and prognostic communication, team conflict, institutional constraints and cultural bias. The theme, “End-of-life (EOL) care inconsistent with personal values” emerged among the RN/OHPs. RN/OHPs experiences were shaped by their proximity to the patient and their role as patient advocate. The MD/APP group reported more cognitive and decisional distress.ConclusionA NICU and palliative care-weekly-collaborative conference resulted in significantly decreased moral distress among NICU staff. Qualitative data revealed that both prolonging life with life-sustaining medical therapies (LSMTs) and ending it by withdrawing LSMTs in the context of prognostic uncertainty and institutional constraints creates significant moral distress among staff. Palliative care and NICU programs should consider implementing regular interdisciplinary collaborative conferences to address this distress.

Nurse leaders can shape ethical cultures

Whom are we seeking to protect? Extremely preterm babies and moral distress

BackgroundPrevention of preterm birth remains one of the most important challenges in maternity care. We propose a randomised trial with: a simple Candida testing protocol that can be easily incorporated into usual antenatal care; a simple, well accepted, treatment intervention; and assessment of outcomes from validated, routinely-collected, computerised databases.Methods/DesignUsing a prospective, randomised, open-label, blinded-endpoint (PROBE) study design, we aim to evaluate whether treating women with asymptomatic vaginal candidiasis early in pregnancy is effective in preventing spontaneous preterm birth. Pregnant women presenting for antenatal care <20 weeks gestation with singleton pregnancies are eligible for inclusion. The intervention is a 6-day course of clotrimazole vaginal pessaries (100 mg) and the primary outcome is spontaneous preterm birth <37 weeks gestation.The study protocol draws on the usual antenatal care schedule, has been pilot-tested and the intervention involves only a minor modification of current practice. Women who agree to participate will self-collect a vaginal swab and those who are culture positive for Candida will be randomised (central, telephone) to open-label treatment or usual care (screening result is not revealed, no treatment, routine antenatal care). Outcomes will be obtained from population databases.A sample size of 3,208 women with Candida colonisation (1,604 per arm) is required to detect a 40% reduction in the spontaneous preterm birth rate among women with asymptomatic candidiasis from 5.0% in the control group to 3.0% in women treated with clotrimazole (significance 0.05, power 0.8). Analyses will be by intention to treat.DiscussionFor our hypothesis, a placebo-controlled trial had major disadvantages: a placebo arm would not represent current clinical practice; knowledge of vaginal colonisation with Candida may change participants' behaviour; and a placebo with an alcohol preservative may have an independent affect on vaginal flora. These disadvantages can be overcome by the PROBE study design.This trial will provide definitive evidence on whether screening for and treating asymptomatic candidiasis in pregnancy significantly reduces the rate of spontaneous preterm birth. If it can be demonstrated that treating asymptomatic candidiasis reduces preterm births this will change current practice and would directly impact the management of every pregnant woman.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12610000607077

Intrauterine growth restriction: new concepts in antenatal surveillance, diagnosis, and management

An ethnographic study of communication challenges in maternity care for immigrant women in rural Alberta