Moral Distress Part 2. When patients make bad decisions.

In the first part, we looked at one type of nurse’s moral distress. We focused on the stress we feel when we witness things that we know are wrong but feel helpless to do anything about it. Or perhaps we have tried to do something but nobody will listen. Today I want to talk about a different kind of moral distress.

This distress is also felt by healthcare professional but it is different because you can’t do anything about it. This moral distress is when a patient is making a decision that you don’t agree with. Patients are allowed, by law, to make their own decisions, including the decision to stop or refuse treatments even when they know they will die because of this decision. Patients have the right to do this because it is their body, not ours. We have to accept it as healthcare professionals but that doesn’t mean that we have to like it. These kinds of situations create terrible moral distress. Imagine having to stand by and watch someone die, when you know there is something you could do to stop it. You would feel helpless and frustrated and angry. These are normal reactions and this is what our healthcare professionals feel when they have to watch us make bad decisions.

If you are the patient, you need to understand that when you show up at the doctor’s office or at the hospital, the doctors and nurses think you are there because you want them to do something for you. Makes sense. But when you show up and then refuse what they have to offer, they will feel helpless and frustrated with you. You are entitled to make your own decisions but please understand that you are making it harder on the healthcare team. They are caring human beings. In no way am I saying you have to do the treatments because of their moral distress, just understand that the people taking care of you will feel the distress. Ultimately, the healthcare professional will have to find a way to live with themselves when you leave their office or after you die.

If you are the healthcare professional in this situation, one way you can manage your distress is to ask the patient more questions about why they are choosing what they are choosing. When you find out their story, you may be surprised by what you hear. Many times I have found myself agreeing with the patient’s decision after I hear the why. Yes, I wouldn’t make the same decision for myself, but it makes sense for them based on their values and beliefs. You can ask the patient if they are willing to reconsider but do not ask them to try to force them to change their mind. They do not have to justify themselves to you. If they don’t want to talk about it or reconsider, please respect this decision. Another technique I use in this situation is I ask them why they are saying no, in a non-threatening or demanding manner. When I do, I may discover that they have some misunderstanding about the treatment, the situation or the side effects. In having a compassionate discussion, oftentimes I can discover what is really worrying them and help them reconsider.

The last way I can offer for you to make peace with this kind of moral distress is to think about it as if you were the patient. Wouldn’t you want the choice and the right to make your own medical decisions? Would you want me to try to impose my values on you even though we might not be from the same culture or religion? You would want me to respect you. And I would. People have the right to make the wrong decisions. (except in pediatrics) This is the gift and the curse of autonomy. I am not saying it will be easy. Coping with this type of moral distress is our special obligation as healthcare professionals.

Part 1 http://kindethics.com/2009/06/nurses-moral-distress/
Have a kind and respectful day.

How do you solve Nurses Moral Distress? Moral Courage – Part 1

Usually I get hired to teach doctors about ethics, communication and improving end-of-life care. Even though I am rarely hired by hospitals to help nurses with the ethical dilemmas they face, it is a privilege for me when I do get to work with them. (Hospitals will pay for the education of doctors but will pay far less money on nursing education.) When I have done ethics rounds with small groups of nurses, tears are shed, stories are told and then I can go through their story and help them work through the experience. Hopefully, they feel better after being heard. They still carry the moral burden of their actions or inactions in the cases from years ago. Sometimes all I can do is to acknowledge their grief and let them know that their instincts were right, even though they felt they were powerless at the time. Then I can help them strategize about how they would solve a similar situation in the future.

Because nurses come into their profession with such compassion and big hearts, their moral distress when witnessing terrible situations is a greater burden to them. Doctors have moral distress as well, but today, I want to talk about the nurses. What is moral distress? It is the distress you feel when you know something is ethically or morally wrong and you feel powerless to change it. And I don’t know about you, but I feel terrible when I feel powerless. Especially when you feel like you’re being forced into taking part in something you know is wrong. I know for the people reading this that aren’t nurses, you might be thinking, “Why doesn’t the nurse just speak up? Why don’t they just say no?” It’s not that simple. That’s not how it works in medicine. Nurses are supposed to follow the doctor’s orders. Just like in the military, you follow the orders of the commander above you. Now, it is much better than it used to be in the past and had nurses have a greater voice on the healthcare team, but it is still difficult to stand up to certain doctors or in certain situations, especially when you think you might get in trouble. So I understand the dilemma nurses find themselves in. But as an ethicist, and I have to say that we need to have moral courage. Otherwise, things will never change. We need to be willing to speak up when we see something that is wrong. If this was easy to do, we wouldn’t call it courage.

The other day I was speaking to a person whose parent was the victim of elder abuse at the hands of a relative. The doctors and nurses saw what was going on. But nobody said anything or reported anything, so nothing was done. The abuse continued because nobody had the moral courage to say no, “This isn’t right.” Another common thing that I see is when a medical error is going to happen and a nurse speaks up to the doctor and says, “I think this medication/treatment plan might be wrong.” Then the doctor may say, “Don’t tell me what to do. Just follow my orders as I have written them.” So what does the nurse do? Well, the first thing she or he does is to experience moral distress. You know it is wrong and you’ve tried to speak up and that didn’t work. Are you going to go to your supervisor? Are you going to refuse to give the medicine or participate in the treatment? What do you do next? If you go to the supervisor, does the supervisor support you and confront the doctor? Maybe no, maybe yes. And maybe you don’t think you have a choice but to give a treatment that you know is wrong. No matter what, you always have a choice. You have your voice.

One thing you can do as a nurse is to take these issues to the bioethics committee at your hospital. You don’t have to be certain that the situation is an ethical dilemma or a moral problem. You can just run it by the person on call and ask for help in evaluating the situation. (You can also use the chaplain for moral support.) Or you can take your concerns to risk management, the medical staff department or administration. Follow the chain of command but don’t give up. You have to persevere to keep the patient safe. This takes courage but I believe in you. You have the moral courage.

I have the moral courage to speak up when I see unethical behavior. And I am no more special than you. Sometimes I get in trouble for speaking up, and sometimes I don’t. But I will continue to speak up because maybe you are the patient in one of my hospitals and I am going to keep you safe. I want to encourage you to do the right thing because I might be a patient in your hospital some day. I might need you to protect me from someone or something that will harm me. I will show you the same respect.

Have a kind and respectful day.