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.

“Age in Place – Putting Your Plan Into Action” Interview with Mark Hager, the founder of Aging in Place. June 24th, 9:30 AM pst

“Age in Place – Putting Your Plan Into Action” Interview with Mark Hager, the founder of Aging in Place. June 24th, 9:30 AM pst. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics.

Mark Hager is the founder of AgeInPlace.com, a website focused on major topics around aging in place, including home modifications, real estate, assistive technology, finances and others. Mark also founded AgeInPlacePros.com, a website for those who provide services and goods to older people, focusing on local businesses meeting community needs brought on by the age boom. Mark is an advocate of planning responsibly for late life to lessen the impact on people, their families and communities. As well as, assisting local businesses prosper while serving those in their communities.

He will be answering the common questions people have about aging in place.

Have a kind and respectful day.

I thought we were all past this. Why are we still keeping gay and lesbian couples from visiting each other in the hospital?

I thought we were past this. I thought this issue was resolved but apparently it isn’t. This week in Fresno – California, a lesbian partner was not allowed in to see her partner of 3 1/2 years in the hospital. If she had said she was the woman’s sister, aunt, or friend she would have been allowed to visit. But because she is in a relationship with the patient, it was not okay. Please, we all have to get over this. It is stressful and scary enough to be in the hospital when you are in a medical crisis. This is when we all need the love and support of the people we love. Put yourself in their shoes. Would you want a healthcare professional keeping you from seeing your sick loved one?  Would you want to wait outside while your loved one dies?  No you wouldn’t.  It is none of healthcare professional’s business who visits you in the hospital. If you believe in the Golden Rule, then please respect that others would want their loved ones to visit them just like you would and don’t let this happen at your hospital.

(FYI: The best way to make sure this doesn’t happen to you is if you write out your advance directive for healthcare decisions. You can write on this document who you would want and not want to visit you. Click on my resouce page for more information about your state’s advance directive form.)

Have a kind and respectful day.

“Are you afraid of getting sued?” for healthcare professionals. An interview with Patricia Coonan, RN on June 15th, 2PM pst, 5pm est..

“Are you afraid of getting sued?” for healthcare professionals. An interview with Patricia Coonan, RN on June 15th, 2PM pst. 5PM est. There were so many listeners with questions, we have scheduled PART 2 coming on June 25th, 2PM pst, answering more questions about doctor’s documentation.

Patricia Coonan will be answering your questions regarding how to protect yourself from a lawsuit. This is a must listen to for doctors and nurses. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics. She will be discussing practical ways to help nurses and doctors stay out of legal trouble by changing your actions and changing how you document.

Patricia been a RN for 24 years and Legal Nurse since 1997. She works for the Beasley Firm as an In-House Consultant and Legal Assistant. If you are being sued, she is the person that would go through the medical records to see what happened and if you have deviated from the Standards, Protocols and Industry Practices and if you may be negligent.

Patricia has also created a training program for those nurses interested in going into the legal field. If you are interested, you can find her products on eBay under Prrn12 or at www.legalnurseprrn12.com or at pc-rn@comcast.net.

You can reach Patricia at Facebook as Patricia Coonan RN, or follow her on Twitter: pcRN.

For legal help, The Beasley Firm website is http://www.beasleyfirm.com and their offices are as follows:
The Beasley Building
1125 Walnut Street
Philadelphia, PA 19107
Phone (215) 592-1000
Fax (215) 592-8360
3000 Atrium Way
Suite 258
Mount Laurel, NJ 08054
Phone (856) 273-6966
Fax (856) 273-6913
Have a kind and respectful day.

“Navigating the Disability Benefit Process” interview with Philip Lewis PhD & J.D. on June 16th, 10AM pst.

“Navigating the Disability Benefit Process” interview with Philip Lewis PhD and J.D.on June 16th, 10AM pst. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics.

Are you recently disabled and need to begin to apply for benefits? Or are you in the middle of trying to receive benefits and are up against a road block? Philip Lewis can help. Philip S. Lewis has worked in the field of vocational rehabilitation since 1979, assessing and providing placement assistance to persons with disabilities. He has been representing persons with disabilities to pursue benefits from the Social Security Administration since 1994. As a professional in private practice, he has provided evaluation services in varied compensatory systems including Workers’ Compensation, Longshore and Harbor Workers, Long Term Disability, and Social Security. Following graduate training in industrial psychology at California State University Long Beach, he earned a Certificate in Human Resources Management from California Lutheran University , and a Ph.D. in forensic rehabilitation and industrial psychology, from the Union Institute Graduate School. He holds a juris doctor degree from the Ventura College of Law, and completed a certificate in Alternative Dispute Resolution at Pepperdine University, School of Law. He maintains board certification as a Certified Rehabilitation Counselor.

He has represented hundreds clients both before the Social Security Administration for initial claims, as well at the Office of Disability Adjudication and Review, for those clients appearing before an Administrative Law Judge. As a former Vocational Expert appearing under contract to the Office of Hearings and Appeals, he has a detailed working knowledge of the procedural and vocational issues raised at the Hearing level. In each case heard at the Office of Hearings and Appeals, a hearing brief is prepared, which outlines the background of the claimant, summarizes the medical conditions as they apply to the “listings of impairments”’ asserts all applicable rules and case law supporting of favorable decision and confirms that in a prevailing case, that an accurate accounting and payment of all past due benefits is effected.

The claimant seeking Social Security benefits based on a disability must be prepared to aggressively pursue this claim. The initial step is filing the claim for either disability insurance benefits and/or supplemental security income benefits. Ultimately, most claimants winning their claim must appear before an Administrative Law Judge and meet the administrative requirement of establishing a disability which precludes all work in the national economy.

Mr. Lewis will be discussing the process of applying for Social Security benefits, the rules of eligibility, program differences (SSI vs. SSDI) supporting medical coverage, benefit entitlement, burdens of proof and time frames, including appeals.

Philip can be reached at http://www.hearingrepresentative.com/ or at 805-642-6080.

Have a kind and respectful day.

Taking The Car Keys Away Part 2 – Dealing with the Emotions

I have been surprised by how many people have contacted me about the issue of taking the car keys away from a loved one. What I want to add to the discussion is that we have to remember to address the emotional issues being experienced by the person losing their driving privileges. They should be angry. They should be sad. These are normal emotions as they come to terms with not only the loss of driving but the loss of their mental and physical abilities. It is a good idea to sit with them and let them speak their mind. All you have to do is listen. Don’t defend yourself. Don’t defend the doctor. Just listen. As you hear their words, think about the day when you will lose your driving privileges and find compassion for your loved one.

One technique you can use is something called active listening. With active listening, what you do is to repeat back the words and the emotions you are hearing. For example, when your mom says, “I am so mad at you for telling the doctor that I shouldn’t be driving anymore.” What you can say is, “I understand that you’re really mad at me mom and that you wish I hadn’t told the doctor.” Your natural instinct is to defend yourself or to explain the reasons you did what you did. This conversation is not about facts, it is about emotions. Just hear your mom’s heart and allow her to experience her feelings. It will probably take a while as you listen and acknowledge her feelings. As she feels heard, she will calm down. And it may take a number of conversations so don’t be upset about this. Don’t you sometimes have to vent more than once about something you are dealing with in your life? Just accept that this is part of her healing process. Hopefully over time, she will come to terms with this loss and move on in her life. But don’t expect her to be happy about losing her ability to drive. It will always be a disappointment.

Lastly, I encourage you to take a look at the first part of the HBO Alzheimer’s special found online at http://www.hbo.com/alzheimers/. It is called, “The Memory Loss Tapes” episode. About halfway through this first section, a woman whose doctor has recommended she stopped driving is put through a driving evaluation test. It is shocking to see how bad it has gotten and that to realize that she just recently lost her privileges. This woman has been a danger on the road for a long time. Please take action sooner than later and save lives.

Part 1, When should I take away the car keys? http://tinyurl.com/c9zjqp

Have a kind and respectful day

“Should you try an experimental treatment if the doctor has nothing else to offer” interview with Carol Mack PhD, June 8th at 9AM pst

“Should you try an experimental treatment if the doctor has nothing else to offer” interview with Carol Mack, June 8th at 9AM pst.

Carol Mack PhD is an oncology nurse and clinical researcher who will be answering the questions you have about signing up for an experimental treatment or Phase 1 trial. Carol did research on patients’ experiences with clinical trials. She is currently an Associate Professor of Nursing at Western University of Health Sciences.

She will discuss the differences between the different phases as well as the ethical questions that need to be asked.

Founded in 1977, Western University of Health Sciences is a nonprofit, graduate university for the health professions. The university campus is located on 22 acres in downtown Pomona, California.

Western University is one of the largest graduate schools for the health professions in California. It currently comprises the College of Osteopathic Medicine of the Pacific, (the founding college), the College of Allied Health Professions, the College of Graduate Nursing, the College of Pharmacy, and the College of Veterinary Medicine. Additionally, it will open four new colleges in August 2009: Dentistry, Podiatry, Optometry, and Biomedical Sciences. Alumni rank among the very top leaders in health care and medicine throughout the country and the world.

All of the health care programs have professional accreditations, and the university is accredited by the Accrediting Commission for Senior Colleges and Universities of the Western Association of Schools and Colleges.

What makes Western University distinctive is its commitment to humanistic values. Underlying a regimen of scientific and technical course work is a strong moral, humanistic approach to education and health care. According to Dr. Philip Pumerantz, the President of Western University, the university uses this humanistic commitment to give its students ” an education that will assist them in becoming humane, sensitive, and technically competent health care professionals. ”

Have a kind and respectful day.

“The World of the Child Who Has Lost Their Parent” interview with Margaret Allan on June 10th at 10AM, pst

Margaret Allan is a LCSW, Licensed Clinical Social Worker with a PsyD, a clinical doctorate in psychoanalysis. She is affiliated with the Institute of Contemporary Psychoanalysis in Los Angeles and is a member of the National Association for Psychoanalysis in Clinical Social Work. Margaret is a psychotherapist in private practice in Westlake Village, CA and works with Hospice of the Conejo as a facilitator in their Family Services, with individual adolescents and in a grief support group for adolescents that meets on Tuesday evenings at HOSPICE of the Conejo. http://www.thewisesource.org/hospice/

Have a kind and respectful day.

KindEthics Newsletter April 2009: Communicating with the Dying

KindEthics Newsletter
The Human Side of Healthcare Ethics
Volume 1, April 2009

Quote of the Day:

“Everyone has an expiration date stamped on their butts. We
just can’t read the date.” -Viki Kind

Feature Article:

Communicating with the Dying

There are many layers to communicating with the dying. It depends
on who the person is, how they are dealing with their own dying
process, your relationship with them and so many other things. So,
what I am about to tell you works with some and not with others.
Or one communication strategy will be appropriate but the other
parts won’t fit. I trust you will know what to do as you help the
individual in front of you.

I didn’t know all of this myself until about 5 years ago when I
became a hospice volunteer. I had aging relatives that I was
responsible for and I felt helpless when it came to dealing with
their deaths. So I went through an extensive training and have
been learning ever since. I am here to share what I have learned.
The first section addresses the months before death and the last
section addresses the last days and hours of death. Both are
profoundly important.

The Early Days of the Dying Experience

People want a safe person to talk to and perhaps you can be that
person for them. You will be giving the gift of conversation to
your friend, your loved one or someone you are working with in your
professional life. As a side note, one thing I struggle with is
when someone doesn’t want to talk. I have to remind myself that
this is this person’s journey, not mine. I am only there to
support them. I tell them that I would be glad to talk to them
about their fears, concerns or hopes for how their death might go.
But I accept when they say, “No thank you.” Maybe they will be
ready another time or maybe I am not the right person for them and
they would prefer to talk to someone else. I don’t take it
personally. I stay present and meet them where they are
emotionally.

Again, everyone is unique. These are just some of the issues
people would like to talk to someone about:

-To know the diagnosis, prognosis and to choose the type of care
-To be treated as a person and not a disease
-To be in an environment of their choosing
-To talk about their fears of abandonment, pain, physical
deterioration and increasing dependence
-To be able to have their family feel they can get along without them
-To have their moods understood and accepted without judgment, such as anger, despair, guilt, denial, resistance or sorrow
-To feel that dying is a natural process and it’s okay to let go
-To be able to communicate honestly with family members regarding their feelings and needs
-To be as pain-free and alert as possible
-To find meaning in their lives, in their suffering and in their death
-To experience their remaining days with awareness and appreciation for life
-To have the respect and love of those who care for them
-To be able to remain in as much control as they are able
-To be able to complete unfinished business
-To be given a sense of purpose in the days remaining

This last one is very important. The other day someone was telling
me about their dad’s failing health. The father was still
completely competent but the daughter had taken over her dad’s
life. Her dad had lost his voice in his own life. And everyone in
the family started to over-protect him. The grandkids would come
over and they would say, “Shush, don’t bother your grandfather.”
This was a grandfather that loved his grandkids and loved
interacting with them. He could still be the grandfather. He
could still matter in their lives. He wasn’t dead yet. Instead I
told her to do her best to keep him included and to let him know
that he matters.

When people are dying, one of the most profound
questions they want answered is, “Did I matter.” Make sure you
tell them not only that they matter but why they have mattered.
Tell them what you have learned from them and how they have changed
your life. Now I realize that sometimes things do need to change
as the person becomes weaker but try to keep the person connected
and valued in the family. I know when my aunt was dying; people
would still come to her room and ask her for advice. She still
mattered. I think this is one of the reasons she held on for so
long. Her work wasn’t done. So, please help the person have their
dignity and value until the end.

The Last Days of the Dying Experience

When people are getting very close to death, maybe during the last
few days or hours, their body begins to change. Because they are
probably no longer eating or drinking, their electrolytes get out
of balance which affects the brain. (The electrolytes work as a
balancing system keeping all of the chemicals in our body in
working balance. Without the proper balance, our brain function is
affected.) Strange things may begin to happen but you don’t need
to be afraid. These signs are normal and natural and I find rather
intriguing. For instance, the person may begin to speak of being
in the presence of those who have already died. This frightens
many families and some people argue with the dying and tell them
that they are wrong or just confused. Why do we need to argue with
them? They are dying! Instead, ask them questions. Who do you
see? What do you see? Tell me about it.

I expected my father to see his mama and papa who he missed dearly and adored.
But he started talking to the empty space right next to meet and kept
saying, “Martin.” I asked him, “Mama?” But he said no, “Martin.”
Then it hit me. His best friend in his childhood and early
adulthood was Martin. His dearest friend had come to guide him on
his journey. Now some people say it is just the electrolytes
affecting the brain and triggering old memories. Others say that
it is truly a guide coming to escort the person to heaven. I don’t
know which one is true but I have been privileged to witness this
part of the journey.

Another thing that happens is that the dying will speak of
preparing to travel or to change. My dad did this. He kept
saying, “The train is late, I have to get on the train.” This is a
common one I have seen many times. Sometimes it is a bus or a
plane or other. But it is a message which tells the loved ones
that the time is getting closer. Other people talk of seeing a
place. Again, ask them about it. Reassure them if they are
confused or frightened. Let them know that they are safe and
whatever they are seeing is okay. Another interesting thing is
that many people will know the time of their death or will keep
asking what time it is. As you begin to leave and you say, “See
you tomorrow.” The dying person might tell you, “No you won’t.”
Sometimes it is absolutely true and sometimes it is wishful
thinking as the person is ready for their journey. The main thing
to remember is that the confusion of the dying is normal. They are
disconnecting from this world and letting go of what has held them
here. There mind is now somewhere else. And this is okay. Again,
don’t argue or judge or discount their experience. Enjoy the ride
with them.

One thing that happens sometimes a few days or a few hours before
death is that the person may have a sudden burst of energy. This
is a gift. For some reason, many people who have been sleeping all
of the time, suddenly wake up and start talking again. This can be
very confusing for their loved ones. They believe that a miracle
is happening and that the person is going to get better. What they
don’t realize is that what is really happening is that death is
even closer. My friend, Amber, told me about her dying horse. Her
beloved horse was dying. He couldn’t leave the stall or walk
anymore. The day before he died, he got this sudden burst of
energy and went out and played with the other horses for a few
hours. The vet had warned her about this phenomenon so she looked
at it as a gift. Her horse had one more bright moment in his life.
And then, hours later, he died a good death. So, enjoy the moment
if you are lucky to get it. If someone comes back to you for a few
minutes or hours, remember it is not going to last forever. Say
anything else you need to say and be grateful you got the chance.

Near the very end, the person will become very unresponsive. That
doesn’t mean that they can’t still hear you or feel your touch.
Talk to them as if they are still with you. Be cautious about
talking about things you wouldn’t usually say in front of them. I
have witnessed families saying in the room, “So what does the will
say?” while the person is still alive. One of the best ways to
communicate with the dying is by touch. Put some lotion on their
hands or their feet and give them a massage. Climb into bed and
take them into your arms. Think about how you would comfort a
child. You would stroke their head, cuddle with them and make them
“feel” loved. As death approaches, tell them you loved them and
that it is okay for them to go. People will hold on for a long
time waiting to hear these words. They want you to say, “I will
miss you but I will be okay. The family will be okay. You taught
me what I need to know so I will be okay. We will take care of
each other.” Or any words like that.

Also, remember that some people need to die alone to protect their
loved ones. Over and over again, nurses will tell me of a spouse
who sits vigil day after day. They never leave to bathe or to eat.
And finally after days of waiting, the spouse gives in and says,
“I am just going to run and get a cup of coffee in the cafeteria.”
And as soon as the person leaves, the patient dies. The spouse
comes back and is devastated that they weren’t there and that they
missed it. I know people that have been shattered by this
experience. But what they didn’t know is that their loved one was
protecting them and didn’t want to put them through witnessing
their death. It wasn’t that the spouse didn’t matter; it was that
the spouse mattered too much. With my dad, he kept holding on for
days and days. Finally I said to him, “I know you need to do this
alone. I am going to go now dad. I love you and I know you won’t
be here when I get back. Goodbye.” I went outside and 20 minutes
later he was gone.” I was glad he was able to let go and do it his
way. People do have to die on their own terms. We can’t control
the process. Even when people are really out of it, they still
seem to die their own way. At the opposite end of the spectrum,
many people can’t let go until either a person or certain people
have arrived. My recent hospice patient was like that. I was
surprised he was still there when I visited him. He had every
physical symptom of impending death but he was still holding on. I
realized his brother was due in about 3 hours and then I
understood. He held on for the brother’s visit and then he died
peacefully.

Ultimately, you just don’t know. You don’t know what your loved
one will need until you are in the moment. Whatever happens is
okay. And you don’t have to be perfect. Just be present and
loving. I always feel so honored to be a part of a person’s dying
process, whether I get to be present in the early days as they are
coming to terms with their approaching death or in the last moments
of the person’s life. It is an incredibly intimate experience and
one that I have been privileged to be a part of. I hope you can
find the beauty and profound nature of the experience as well. If
you have other questions, feel free to contact me at
viki@kindethics.com.

Subscribers Comments:

Elizabeth P from New Jersey
“Viki helped me in my crisis. There was no wait, no down time, and
she knew her stuff!”

Wheelchair Etiquette and Safety aka The Day Aunt Berda Rolled Away

Dear Viki,

Why don’t people help when they can see you are in trouble? The other day I was trying to get my father in his wheelchair through a narrow doorway when some guy pushed his way through ahead of us and then let the door slam on my father’s foot.

As someone who has been pushing relatives in wheelchairs for 25 years, I know how difficult it can be when nobody will open the door or give you a hand. I also hate it when someone parks really close to the edge of the handicap parking space. I remember trying to get my mother, who could barely stand, out of the car and into her chair. Even on the best of days, it wasn’t easy. And when someone parks too close, then you can’t roll the wheelchair up, put the chair at an appropriate angle and then get the person out safely.

The other day, I saw it again, a lady trying to push her mother in a wheelchair through a heavy door. Nobody stopped to help. I did because I know that it isn’t easy to manage a heavy door with one hand and try to push a heavy wheelchair through the doorway. So please notice the next time you see someone struggling, stop and ask if they need help. Always ask first. And then respect their answer and provide help if they would like you to help.

And one more thing, don’t forget to always use the brakes on the chair. Not some of the time, all of the time. One day I forgot to and my aunt went rolling down the parking lot incline. She and I had a good laugh about it because we knew she could stop herself, but the man who came running across the parking lot to help didn’t know that and was in a panic. We felt badly that we had scared him. After that, Berda and I set the brakes to protect her and those good people that cared about her safety.

Have a kind and respectful day.

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