Role of chaplains in end-of-life care: Case studies on healing

Sam, a middle-aged Black cisgender male (they/them), was admitted for an organ transplant during the first wave of the COVID-19 pandemic. At that time, visitation was heavily restricted: only compassionate exceptions were allowed for patients at the end of life, those whose care required life-altering decisions, or patients with disabilities who required additional assistance. Organ transplant recipients were considered particularly vulnerable because of immunosuppression. Virtual technologies such as smartphones and tablets were used for patients to communicate with their families, but Sam would often decline calls from their spouse, Alex. Several months went by and Sam was still in our care; they had complications of infections and ultimately experienced multisystem organ failure. After the transplant graft failed, it was decided that Sam would be moved to a unit that allowed one designated visitor. When nurses asked Alex whether they would be able to visit, Alex became defensive and began to communicate in a way that some nurses felt was threatening. Alex explained that they needed to continue to work and could not make the long journey to the hospital multiple times each week. Sam continued to deteriorate and on their final day, Alex and Sam's lifelong friend both came to the bedside. A music therapist and spiritual caregiver provided final services, and the intensive care unit (ICU) nurses experienced the death of another patient for whom they had cared for many months and who had spent their final months isolated from friends and family.Critical care nurses face complex ethical decisions on a daily basis, and these decisions have been magnified by the SARS-CoV-2/COVID-19 pandemic. Ethical considerations are apparent when nurses are involved in life-altering decisions such as withholding or withdrawing life-sustaining treatments, organ transplantation, and surgical candidacy. By contrast, "microethics" captures the ethics of everyday clinical practice and emphasizes the ethical impact of day-to-day interactions and relational considerations.1 Adopting this "view from the inside," here we focus specifically on new virtual visitation practices and their impact on patients, their loved ones, and nursing care.1 Cuchetti and Grace2 previously argued that nurses should adopt a critical stance and use "intentional authenticity" when using technology to maintain the patient-nurse relationship. Intentional authenticity requires that nurses make authentic and intentional choices regarding the use of technology in specific situations, understanding its potential positive and negative effects on patient care.2 In this article we consider how COVID-19 has brought many microethical issues to the forefront and adopt a critical stance through which to explore the ethical trade-offs nurses face when they choose to use technology for virtual visitation. Using Sam's case as a basis, we consider the ethical complexities and repercussions of virtual visitation, in particular the way in which technology has both connected loved ones and exacerbated social inequalities throughout the pandemic. At the forefront of the discussion are considerations of equity, safety, trust, and nursing obligations to maintain relationships with and between patients and their loved ones.3The COVID-19 pandemic has required critical care nurses to quickly change many of their practices in order to protect communities within and beyond hospital walls. In many places, visitation was almost entirely restricted, including for patients who were confirmed or likely to have contracted COVID-19.4-6 Nurses and health care systems shifted to offering virtual visitation using smartphones or tablets. The absence of visitors created logistical and ethical challenges for nurses and patients in building and maintaining relationships with loved ones, and, we argue, it also impacted decision-making.Nurses have grown accustomed to frequent changes in practice as technology has advanced, and the recent nursing literature contains discussions about the long-term impact of these changes on nursing care and the healing environment. Treatment modalities such as extracorporeal membrane oxygenation, left ventricular assist devices, and total artificial hearts have created new liminal spaces between life and death.7 Nurses practicing in critical care settings have long been warned about the risks of becoming too distracted by the complex life-sustaining machines such that they risk overlooking the relational needs of the patient. New informational technology used for interfacing with patients creates additional barriers between nurses and patients. Electronic documentation requires nurses to spend hours staring at computer screens in order to chart and receive reminders for upcoming interventions. Exploring the use of smartphones, computers, tablets, and the internet, Cuchetti and Grace2 described how these technologies have the potential to dehumanize patients. Throughout the pandemic, however, we have seen how these technologies have brought people together; rather than serving as a barrier, they have acted as a bridge between patients and loved ones and have enabled health care workers to understand their patients in the absence of in-person visitation.Family presence in the critical care setting is considered an essential component of care and a key element of ICU liberation bundles.8 Provision 1 of the American Nurses Association Code of Ethics for Nurses states that nursing support extends beyond the patient to also include the family.9 For the purposes of this article, we use the term family broadly to include relatives, friends, and other individuals whom the patient considers support persons. For patients, visitation has psychosocial benefits such as reduced anxiety, confusion, and agitation, and physiological benefits including fewer cardiovascular complications and shorter length of ICU stay.10 For loved ones, visitation increases satisfaction, decreases anxiety, promotes understanding of patient care and preferences, and allows more opportunities for education.10 Despite the known benefits of visitation, in order to maintain safety for patients, health care workers, and the broader community and to reduce the spread of SARS-CoV-2, visitation has been heavily restricted.11,12 Such restriction can also be interpreted as supported by the American Nurses Association Code of Ethics: provision 3 states that nurses have an obligation to protect the rights, health, and safety of patients, and provision 5 stipulates that nurses owe the same duties to themselves and others.9In Sam's case, because of their immunocompromised state, they were completely restricted from seeing their spouse in person for months. Sam, like many other patients, lost the important role their family might have taken to assist with eating and grooming and to provide companionship. The lack of family presence impacts the healing environment that we try to create for patients.13 In an attempt to connect patients and families, many health care organizations used tablets to facilitate visual connections. Considering digital health technologies and relational geography, Peter14 states that "geographers recognize how spaces are created through social interactions and are viewed to be ever-changing, creating 'social space.'"(p138) By removing visitors from health care settings and instead using virtual technologies, we change the social space of the healing environment.For patients who are able to participate in virtual visitation, the use of technology created ways for them to stay connected to family and friends from the comfort of their hospital room while maintaining safety. Whereas many ICUs previously may have discouraged use of smartphones, they now promoted digital connection to reduce patients' social isolation. In Sam's case, despite restricted in-person visitation, they frequently asked the nurse to decline virtual visitation and phone calls, stating that they did not feel up to communicating. Many members of the nursing team felt uncomfortable informing Alex of this, but they also recognized that Sam understood their choice, and so declining virtual visitation promoted Sam's autonomy. Although connection to family may be important to some patients, nurses need to recognize that not all patients may feel comfortable with virtual visitation.13 Nurses have an ethical obligation to support a patient's right to self-determination,9 which may include maintaining the patient's privacy rather than using virtual technology, even if this choice upsets family members.The shift of ethical obligations and priorities during the pandemic has contributed to moral distress. We understand moral distress as psychological distress one experiences in response to a morally challenging event. Morley et al15 describe 5 subtypes of moral distress (see the Table). We have encountered many nurses who have expressed moral-constraint distress when required to facilitate virtual visitation. Whereas many nurses believe that it is their responsibility to connect patients and loved ones, they also have expressed frustration and anger because they have so many competing responsibilities to other acutely ill patients. Nurses continue to struggle with high acuity and understaffing due to colleagues contracting COVID-19 or leaving the profession. The nurses who remain have found themselves responsible for facilitating updates to families through phones or tablets, which is time-consuming. On COVID-19 units, many nurses expressed feeling that the expectation that they would spend more time in patient rooms to facilitate virtual visitation and perform tasks typically performed by persons in other roles, such as emptying trash, was unfair and potentially increased their risk of COVID-19 exposure while consulting services safely worked remotely. This perspective may be countered by arguing that virtual visitation still reduces one's risk of exposure to COVID-19 when compared with in-person visitation, but nonetheless, many nurses have expressed feeling that they have shouldered a disproportionate burden of responsibility during the pandemic.3In facilities that previously offered 24-hour visitation, families may request continuous video feeds to replace in-person visitation. This request may not seem unreasonable given the lack of access to their loved ones, but it does create ethical questions about both patient and staff privacy and fair allocation of resources, given that most units are not likely to have access to multiple continuous video feeds. We might decide to add video feeds only for the most critical patients so that loved ones can feel more connected, or for patients who might be considered to be particularly vulnerable. Many interventions provided in the ICU, however, can be temporarily painful, and though nurses provide these interventions with the long-term goal of helping the patient to recover or heal, this aim may not be readily apparent to family members watching the video feed. Repositioning and tracheal suctioning may hurt temporarily, but without these interventions the patient may experience complications due to skin breakdown or be unable to breathe. Families can be educated virtually about the clinical indications and risk-benefit trade-offs for an intervention, but the context of care can be lost in a continuous feed. A family might miss a nurse's comforting touch, reassurance, and coaching through a painful intervention. Nurses may experience moral-uncertainty distress in wanting the family to feel connected but being unsure about whether an incapacitated patient would want to be recorded. Once a video feed is started, families can take photos or make permanent recordings of the video showing the patient or the nurse. Families might also observe an error, and although health care professionals have an obligation to disclose errors, information could be misinterpreted, or family access to information about who was responsible could jeopardize therapeutic alliances and undermine patient care.In Sam's case, Sam had the capacity to make decisions and could agree to, or indeed decline, virtual visitation. Many patients, however, are unable to provide permission and discover upon their recovery that they have been included in video calls. In a study of health care professionals from the United Kingdom, survey respondents reported the perceived distress this caused to families when practices varied between units and hospitals. Some units would facilitate virtual visitation without patient consent, whereas others required such consent.5 This variation in practice highlights the need for institutions to develop standard protocols and procedures.Disputes with patients or their surrogates about visitation can create moral-conflict distress for the nursing team. Sam would frequently decline phone calls and offers of virtual visitation through a tablet, which created conflict between Alex and the health care team. The health care team believed that they were frequently giving Alex updates, but Alex expressed frustration and accused the team of "not letting me talk to Sam"; Alex also often expressed feeling that they did not have sufficient information to serve as Sam's surrogate decision-maker. The pandemic has probably exacerbated workplace violence as a result of higher stress and anxiety among patients, families, and health care workers, leading to an increase in verbal threats.16 Verbal threats are less likely to be reported than physical violence, which suggests that health care organizations may not be robustly capturing this negative impact of the pandemic. In Sam's case, many nurses expressed feeling that Alex spoke in a threatening tone. Although nurses should not be subjected to verbal or physical abuse in the workplace, we have noted times when health care workers' own racial or socioeconomic biases seem to affect their perception of an individual or a situation. A balance must be struck between supporting nurses who perceive that they are experiencing verbal abuse and addressing biases. Nursing ethics has a long history of commitment to social justice, and working to address unjust systems must be balanced with a nurse's duty to themselves and no tolerance for verbal abuse.9,17 We found it helpful to encourage the nursing team to engage in perspective-taking and consider why Sam's partner might express anger. For example, Alex might have felt guilty that they were unable to visit and frustrated that Sam kept declining their attempts to communicate virtually. During times when in-person visitation was not restricted, Alex might have felt angry that they were unable to take time away from work to visit, or indeed, they might have been angry about ongoing structural injustices that have meant that COVID-19 has disproportionately affected Black communities and other people of color.18Nurses are frequently told that their health care institutions take a zero-tolerance approach to workplace violence, but in reality, complex dynamics frequently mean that allowances are made for patients or visitors who are verbally abusive or violent. For example, consider patients who lack decision-making capacity and are violent, or visitors who have extreme emotional reactions but are able to return for compassionate reasons such as end-of-life visitation. Even with virtual options available, many family members understandably felt strongly that they should be able to see their loved ones despite the necessity of visitation restrictions. The responsibility for consistently enforcing and reinforcing institutionally mandated visitation policies and restrictions often falls to clinical nurses at many health care organizations. Such institutional changes can result in moral-constraint distress, as nurses are required to shift from focusing on caring relationships to reinforcing institutional rules that they might not agree with. This shift potentially risks the therapeutic and collaborative relationships that nurses in an ICU work to build with patients' loved ones.Many nurse managers and leaders stepped in to support clinical nurses and found themselves in the position of interpreting hospital policies that necessarily allowed for compassionate exceptions. Nurse managers experienced moral-conflict distress as they tried to balance these ethically laden considerations. Reflecting after a severe acute respiratory syndrome outbreak in the early 2000s, Rogers19 highlighted the need to examine ethical repercussions of visitation restrictions for future health emergencies. Rogers concluded that because health care workers have a duty to care for patients and families, organizations must accept responsibility for both making and enforcing visitation restrictions. Many health care institutions, however, found that they were not prepared for the COVID-19 pandemic, and fielding the frustration and anger of families experiencing restrictions fell to bedside clinicians.19Many organizations made exceptions to allow for in-person visitation, but disparities may be exacerbated if exceptions are made solely by individuals. Importantly, exceptions might be made more often for patients who do not have COVID-19 in order to preserve personal protective equipment and the perception of a lower risk of spread, meaning that patients with confirmed COVID-19 are less likely to receive visitation exceptions.18 As we mentioned, the COVID-19 pandemic has disproportionately affected people of color, further amplifying racial injustice.Issues related to access that create microethical complexities must also be considered when using virtual technologies. Patients who do not have their own device or are unable to hold a device must rely on the availability of hospital equipment and an employee to assist them. Patients with visual or hearing impairments may not be able to use the technology effectively, raising the question of whether visitation policies should allow exemptions for this patient population. Families may not have access to the technology required for virtual visitation, such as a high-speed internet connection and a phone or computer with a camera, and many resources that were previously available, such as libraries and community centers, have been closed. Older adults and other individuals may not feel comfortable using the technology. Because of the unprecedented nature of COVID-19, rapid changes were required to ensure that patients and families were not entirely isolated. Moving forward, health care institutions and services should consider ways they can bridge the "digital divide" and ensure equitable access to devices in order to facilitate virtual visitation.Families are often overwhelmed the first time they come into an ICU. As they sit by the patient's bed each day, they may observe the patient deteriorating and see subtle changes in the patient's condition. When these visits happen at a distance, the family may visualize their loved one for only a few minutes a day, if at all, and rely on complex information from a team with whom they have had less opportunity to build a relationship. When Sam was acutely ill and lacked decision-making capacity, the health care team often had to call several times in order to reach Alex to discuss the risks and benefits of recommended interventions and obtain informed consent. Alex frequently did not answer the phone and requested more time to make decisions. This raised questions for many members of the health care team about Alex's reliability and understanding of the situation. Health care teams depend on families to act as surrogate decision-makers and ask them to make decisions on the basis of substituted judgment or best interests.20 Such decisions require knowledge of complex an understanding of the patient's and preferences, and a with the health care team. information and building can be made more when using virtual A the pandemic that surrogates to patients' end-of-life in of who are not able to be at the bedside may it even more to make complex decisions. The health care team and the family may experience distress as they attempt to these many health care visitation exceptions included end-of-life After months in the ICU, Sam began to deteriorate by institutional the health care team made exceptions to allow both Alex and Sam's friend to come into the ICU. After they of Sam at the bedside. teams that had supported Sam throughout their stay came to their final In the after Sam's many nurses of and Sam had of clinical that allowed family to be in their is not of continue to that most patients want family members during and at the end of life, and that families feel that it is their duty to be during and for the family include lower of stress and Families who may previously have been unable to make it to the hospital can now be offered the of being however, we do not whether those same benefits to virtual In these one nurse can hold the while another that is and for that the family may want to end the virtual During in-person visitation, a nurse would continue to comfort the family and in spiritual care microethical decisions about whether to sit with the family or hold their are of a During virtual after a patient a nurse can and the but this may feel both and for a family and the nurse's to care for the of a may depend on one's but nurses in the United perceive as a the to be connected with a loved one at the end of feel a moral obligation to provide this of a death to the patients in their Nurses have been to the of but the impact of a and to ensure that the patient that presence at the end of their life is Many nurses and other health care workers may experience moral-constraint distress because they feel by their to provide only this virtual connection and a moral Nurses may act as a surrogate which increases their psychological burden and emotional and many an emotional in hearing the of families to their loved the COVID-19 pandemic, technology began to be used in order to preserve therapeutic and relationships for patients. The use of virtual technology has had both positive and negative ethical and, as we have it has created microethical for critical care In a survey by et health care professionals perceived benefits to patients of virtual technology, such as reduced psychological distress the to patients and patient with physical also reported an increased of from seeing their patients connect with loved ones however, multiple barriers to virtual visitation, such as a lack of staff to facilitate a lack of family access or families to use devices, and privacy As the pandemic we must continue to consider the ethical issues technology has such as equitable access to technology, safety, moral distress, and increased nursing those who have access to the technology, virtual may have some of the barriers and risks to visitation. Black and individuals have had higher of during the which impact the to to visit loved Black and individuals in also are more likely to rely on which a risk of exposure to Although virtual visitation may provide from it is not an for As Cuchetti and Grace2 nurses need to take a critical stance when the use of virtual technology in have experienced distress as they have tried to balance their obligation to care for patients and to maintain their own personal safety throughout the pandemic. virtual visits is nurses would up the tablet, provide an answer and the with the patient so that they can continue with other care As we continue to provide virtual visitation, nurses should be offered on the technology and be given the opportunity to ask questions related to its Nurses would probably from about how to communicate and with patients and families about to need to provide on how to address ethical such as the use of technology and policies regarding access continuous 24-hour Many in the United have ethical for during the pandemic, but this does not include the ethical use of virtual technology in the et noted that many on from the United on the of virtual visitation, but varied regarding was in a patient's best Virtual visitation may support relationships between patients and their families, but it also increases emotional and for is important to recognize that to virtual for visitation, for patients who are at the end of life, may have a impact on who may experience stress and of moral distress. should provide resources to address both psychological and moral distress among health care workers and The pandemic has new ethical challenges and exacerbated and resources should be to address moral distress, such as ethics services for decision-making at an individual and a and moral distress provide nursing we must be critical and about the ways in which we use technology. The COVID-19 pandemic has required changes to be We forward, it be important to technology with a for ongoing of a and its impact on the the the and the practice environment. The pandemic has required in which and making do not at the bedside. In order to may be with team members in Virtual updates to families may during these both of these risk bedside nurses and potentially patients. Because nurses are with patients and often act as the with the patient and the must to ensure nurses are included in the decision-making as their would is a of that individuals as and can when nurses are not into at that in ethical practice nurses must be teams must work leaders must support resources should be and policies must be that protect we to life with COVID-19, we that virtual technology would facilitate and a between nurses and We have seen throughout the pandemic how technology can to some patients and loved ones, and As with many other of this pandemic, however, use of such technology in the ICU setting issues of justice, and Sam, in their immunocompromised state, and was able to their in when to have virtual virtual visitation and did not replace in-person these technologies are available, they have to understanding of patients and to rather than the patients for whom we

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:

Communication is a way in which humans make sense of the world around them. Communication takes place as an interactive two-way process or interaction, involving two or more people and can occur by nonverbal, verbal, face-to-face or non-face-to-face methods. Effective communication is described to occur when the sender of a message sends their message in a way that conveys the intent of their message and then is understood by the receiver of the message. As a result of the communication from both the sender and the receiver of the message a shared meaning is created between both parties.Communication can therefore be viewed as a reciprocal process. In the health care literature the terms communication and interaction are used interchangeably.Communication failures between clinicians are the most common primary cause of errors and adverse events in health care. Communication is a significant factor in patient satisfaction and complaints about care. Communication plays an integral role in service quality in all service professions including health care professions.Within healthcare, quality care has been defined by the Institute of Medicine as 'care that is safe, effective, timely, efficient, equitable and patient-centred'. Patient-centered care is defined as 'care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient's values guide all clinical decisions. Patient centered-care encompasses the 'individual experiences of a patient, the clinical service, the organizational and the regulatory levels of health care'. At the individual patient level, patient-centered care is care that is 'provided in a respectful manner, assures open and ongoing sharing of useful information in an ongoing manner and supports and encourages the participation of patients and their families'. Healthcare organizations that are patient-centered engage patients as partners and hold human interactions as a pillar of their service.The deepening evidence base for principles and practice of patient-centered care has resulted in increasing recognition of, and greater focus on, the engagement of patients, and the value and benefit of patient engagement. Contemporary healthcare policy across the globe increasingly supports the engagement of patients as partners in all aspects of their own health care and also in systemic quality improvement. In 2005, the World Health Organization's (WHO) World Alliance for Patient Safety established the Patients for Patient Safety program, to improve patient safety globally in collaboration with patient advocates across the world. As a global initiative, Patients for Patient Safety 'believes that safety will be improved if patients are placed at the center of care and included as full partners'.In 2011 the United States of America Department of Health and Human Services announced its commitment of one billion US dollars of federal funding under The Patient Protection and Affordable Care Act 2010 and launched the Partnership for Patients initiative. The Partnership for Patients public-private consortium, which focuses on patient safety improvements and draws membership from federal government agencies and over 8000 health care providing organizations and individuals, views patients 'as essential partners in improving safety and quality' and 'their participation as active members of their own healthcare team is an essential component of making healthcare safer and reducing readmission'.In Australia, as part of national health care reforms to improve access to care, the efficiency of care and public transparency of the performance and funding of health services, the Australian Health Ministers endorsed the 10 National Safety and Quality Health Service Standards (NSQHSS) in 2011 and the Australian Safety and Quality Goals for Health Care (The Goals) in 2012. The NSQHSS focus on partnerships with health consumers in their own care and treatment and also in health service planning, the design of care and service monitoring and evaluation. Standard 1 - Governance for Safety and Quality, and Standard 2 - Partnering with Consumers, are required to be integrated within all of the other eight Standards.With patient safety and quality being core to the delivery of care the Safety of Care, Appropriateness of Care and Partnering with Consumers goals have been identified as the three areas that will make up the goals over the next five years until 2017. The Australian Commission on Safety and Quality in Health Care, in providing further justification for the focus on these three areas, states:The third priority area of The Goals, Partnering with Consumers, reflects patient-centered care practice by ensuring 'that there are effective partnerships between consumers and healthcare providers and organizations at all levels of healthcare provision, planning and evaluation'. Specifically, 'Consumers and healthcare providers understand each other when communicating about care and treatment and health care organizations are health literate organizations''.As healthcare focuses on providing services that are patient-centered and methods to ensure this occurs, patients' voice and experience of health care provision is increasingly being sought from an organizational quality improvement perspective. Patients are being surveyed on their healthcare experience across interpersonal areas such as being provided the opportunity by their health professional to ask questions, the level of involvement in their own care and whether they were shown courtesy, treated with respect and listened to carefully by their health professional.Surveys of patients' satisfaction with their care are now being superseded by surveys of patient experiences of care. However, current methods used to collect and use information from patients about their care is often retrospective, provides inadequate real time data and is not effective in creating action to produce change at the individual patient level. Methods which focus on including the patient and their information in real-time are considered by many to be crucial to the advancement of improved health outcomes and the reduced costs that are required of health care to be sustainable. One such method is patient-centered communication.The nurse-patient interaction is a core component of nursing science and high quality nursing care. Fleisher et al. contend that 'the main intention of communication and interaction, in the health setting, is to influence the patient's health status or state of well-being'. As a profession, nursing predominately requires communicating with, and relating to, patients at the individual level. In the hospital setting nurses undertake many of their patient related duties in a face-to-face manner with the patient at the bedside and these moments can facilitate effective interaction to occur between the nurse and the patient, which is patient-centered. McCabe et al. state that patient-centered communication as "defined by Langewitz et al. as 'communication that invites and encourages the patient to participate and negotiate in decision-making regarding their own care'.''However, qualitative studies by McCabe and Wellard et al, highlighted that nurses interact with patients only when performing administrative or functional activities and nursing 'practice was predominately task-orientated'. The outcome of these studies are supported by Maurer et al. in their report on the tools and strategies available to support patient and family engagement in the hospital setting. Maurer et al. identified that current strategies 'are not attuned to patient and family member experiences of hospitalization' and that most tools and strategies were 'more reflective of health professional and hospital views and the organization of their work'. The report identified a gap in the initiation of engagement, which is not driven by the patients and families' needs and preferences as they occur but by the 'opportunities that the hospital makes available'.McCabe et al. also argue that nurses' attending behavior, that is their 'accessibility and readiness to listen to patients through the use of non-verbal communication' requires that they have the underpinning elements of 'genuineness, warmth and empathy' all of which are components of patient-centered communication. McCabe et al. observed that 'that nurses do not always communicate in a patient-centered way'.According to Fleischer et al. 'The listening behavior in the way of listening and asking actually is the beginning of the nurse-patient communication relationship' McCabe et al. state that the lack of recognition and support by healthcare organizations of the connection and subsequent importance of patient-centered communication in the provision of high quality care has promulgated a culture averse to patient centered communication and is a significant factor in reducing the value that nurses place on providing patient-centered communication to patients.It is apparent that tensions exist between service quality and patient-centered care principles and practice. The impact of this tension on care and the patient as an individual is reflected in the literature. McCabe et al. claim that the use of non-patient-centered types of communication can negatively affect a patient's sense of well-being and security. Horvey et al. detail patient and family member experiences of not being listened to by their health care providers and describe the resulting consequences to be as severe as the death of the patient during their hospital stay. (ABSTRACT TRUNCATED)

Health care is changing. The technologies available for diagnostics are improving. The methods of acquiring and sharing information are burgeoning with the advent of the electronic medical record and information technology. Care is expected to be patient-centered, ensuring that the patient and familyunderstandtheoptionsavailable for treatment and are the decision-makers guiding care. In addition, health care is increasingly team-based. A broadly accepted definition of team-based health care is “the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care” (1). “The high-performing team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system” (2, p. 3). With the literature burgeoning with new research findings, and with the research evidence that serves as the metric for quality of care continually changing, no single physician can absorb all of this information. Physicians must rely on specialists in other fields. Patient consumers are frequent utilizers of physician services. For example, the “typical Medicare beneficiary visits two primary care clinicians and five specialists per year,” as well as utilizing the ancillary services of diagnostic radiology, laboratory testing, pharmacy, and other services (3). Individuals suffering frommultiple

APhA advances provider status initiative

The MediStori. A personal health record and standardised self-management toolkit which can improve integrated care systems

This research explores how registered nurses constructed their leadership role during the provision of health care services in acute care, adult hospitals in Brisbane, Queensland, Australia. As health care organizations change to meet the demands of the twenty first century, nurses in Australia are coming to realize there is a dissonance between what they perceive to be the relevance of their work and the perception of the relevance of nurses' work by others in the health care system. Consequently, nurses' contributions to health care services are not recognized. The literature highlights that one way to address this problem is to articulate the various leadership roles contemporary nurses are asked to undertake. This is the aim of this thesis. This research seeks to illuminate the role of the nurse within changing health care systems by making clear the nature of their work through the perspectives of leadership. Consequently, the purpose of this study is to explore how nurses have undertaken leadership initiatives in their role as health care providers within contemporary health care organisations. The literature review generated following research questions: 1. How do nurses describe leadership within their health care organisations? 2. How do nurses experience leadership within their health care team? 3. How do nurses construct their leadership role whilst providing health care services? In order to legitimate its findings this study aimed to provide a clear theoretical framework. In order to gain a clear understanding of the personal experiences and meanings of the participants, the theoretical framework for this study was underpinned by the interpretive philosophies the epistemological framework of constructionism and the theoretical perspective of symbolic interactionism. The methodology of case study enabled an empirical investigation of a contemporary nursing phenomenon, leadership wherein the researcher was able to pose questions to those nurses from whom most could be learned. Data were collected through two stages. In stage one, the exploratory stage data was collected through three focus group interviews. Stage two aided deeper exploration of the nurses' leadership constructs with data obtained through one-to-one interviews. Analysis of the data enabled the development of a model of nurse leadership. Participants identified that their leadership was constructed through three perspectives of Self as Leader, Self and Others and Self in Action. The findings contrast the nurses' unique leadership constructs to those of health care organisations, highlight the lack of acknowledgment for nurse leadership within health care teams, and demonstrate how the nurses' leadership constructs influence their decision to act in the provision of patient care. This study concludes that as the nurses come to realise traditional leadership models are incompatible with their goal of achieving patient centred care, they have developed a different style of leadership to achieve their vision of patient centred care. Finally this study offers recommendations in the areas of nursing practice, nursing education and research.

APhA2015: You made it a success!

Action brief: Patient engagement and activation: A health reform imperative and improvement opportunity for nursing

Millennial Health Care: Change You Can Believe in

The Pediatric Bill of Rights

The aim of this article is to examine the spiritual counseling and care services in Belgium. In this context, the history of spiritual counseling and care in Belgium, its areas of practice, and the challenges faced in services provided to Muslim minorities are discussed. Considering that this field is newly developing in Turkey, it is emphasized that benefiting from the experiences of countries with well-established practices is of great importance. Accordingly, the necessity of studies that will contribute to the Turkish literature on spiritual counseling and care services in Belgium is highlighted. The documentation technique was preferred in the article, and sources in Turkish, English, Dutch, and French containing information about spiritual counseling and care services in Belgium were utilized. Based on the findings, it has been determined that spiritual counselors in Belgium operate in churches, hospitals, social services, and prisons. These services play a significant role in meeting the psycho-spiritual needs of various seg-ments of society. Additionally, it has been revealed that spiritual counseling and care services have a positive impact on individuals' psychological well-being. While there are many higher education institutions in Belgium that train spiritual counselors for Christian communities, there is no higher education program for training spiritual counselors to serve the Muslim minority group. However, some universities offer certificate programs, and relevant undergraduate and postgraduate programs are available at the Brussels Faculty of Islamic Sciences, established in 2007. This situation indicates that the institutionalization of spiritual counseling and care services for Muslim immigrant communities is limited. The most fundamental issue in services for Muslim immigrants is the training of qualified spiritual counselors. Although the Belgian government has permitted the establishment of institutions in this field, solutions regarding the recognition and equivalence of diplomas issued by these institutions remain insufficient. Furthermore, the lack of adequate roles assigned to Muslim counselors, especially in hospitals, stands out as another significant issue. These deficiencies restrict the access of Muslim immigrant communities to spiritual support services. In conclusion, despite the current challenges, positive developments are being observed in this field, and it can be predicted that Muslim immigrant communities in Belgium will be able to benefit more effectively from spiritual counseling and care services in the future. These developments will contribute to making the services more inclusive and sustainable. Moreover, equality-based approaches in service delivery will enhance respect for religious diversity.

Evidence-based practice collectively involves research evidence, clinician expertise, and patient preference while making health care decisions. Due to health care reform legislation, there is grea...

Due to the SARS-CoV-2 pandemic, healthcare workers (HCWs) are experiencing tremendous levels of emotional and physical stress. Hospitals are trying to help personnel cope with work-related pressure. The aim of this study was to assess HCWs' awareness and utilization of counseling and support services during the pandemic, HCWs' unmet counseling and support needs, and the type and content of these services. A cross-sectional online survey was conducted from January to June 2021 through the German national research organization Network University Medicine (NUM). All participating hospitals (6 in total) were asked to inform their employees about the study. A total of 1,495 HCWs were included in the analysis. Of these, 42.8% (n = 637) were frontline HCWs (who had contact with COVID-19 patients), 23.1% (n = 344) were second-line HCWs (who only had contact with non-COVID-19 patients) and 34.1% (n = 508) had no contact with any patients. Participating hospitals offer various counseling and support services for their staff. The percentage of respondents who were unaware of available counseling and support services ranged from 5.0 to 42.0%. Depending on the type of counseling and support services, 23.0-53.6% of the respondents indicated that counseling and support services were provided but not used, while 1.7-11.6% indicated that, despite the need for them, such services were not available. HCWs' overall satisfaction with the provided counseling and support services and their unmet support needs differed by patient contact: Frontline HCWs reported more unmet needs for counseling and support than second-line HCWs, while second-line HCWs reported more unmet needs than HCWs without patient contact. The results indicate that hospitals should make more efforts to inform HCWs about available counseling and support services. Hospitals could also create networks where HCWs could share information about the type and content of services and their experiences with various counseling and support services. These steps would enable hospitals to respond more quickly and effectively to the problems facing HCWs during pandemics.

Today’s health care delivery has evolved from a physician-centered model into a more patient-centered model. Although the definition and boundaries of the patient-centered health care movement are still being developed and refined, patient-centered care is arguably distinguishable, both historically and conceptually, from public health. Nonetheless, just as public health concerns and individual medical choices have come together in some health care decision-making contexts for centuries, contemporary questions such as whether hospitals should mandate annual influenza vaccinations for their health care workers involve legal and ethical principles underlying the patient-centered movement, most notably that of informed consent. This article discusses some of the legal arguments addressing health care employers’ mandatory influenza vaccination policies in the United States. In particular, we examine the relationship between influenza vaccination mandates imposed on health care workers by private sector employers and informed consent to vaccination, in the absence of federal or state vaccination requirements. This article proposes that the practice of requiring employees to sign a consent form when they receive the influenza vaccination as a condition of continued employment conflicts with the ethical and legal doctrine of informed consent, and concludes that when an employer’s policy effectively removes an employee’s freedom to choose whether to become vaccinated, it is unethical to require that health care worker to sign a consent form. The article advocates that if, despite controversy over such policies, employers choose to mandate immunization, they provide an alternative form, so that health care workers who would not seek vaccination except to avoid termination of employment may acknowledge that acquiescence to vaccination is informed but not voluntary.