Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate

Moral Distress and Austerity: An Avoidable Ethical Challenge in Healthcare

Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect-moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians' moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times.

Moral distress in veterinarians

Moral distress is a psychological state of anguish that has been widely studied in healthcare professionals. Experiencing moral distress can lead to problems including avoidance of patients and increased staff turnover. Moral distress in veterinarians has not yet been explored to the extent seen in the human medical field, and there is limited data regarding moral distress in veterinarians. However, it is expected to be prevalent in these professionals. So far, it has been reported that veterinarians commonly experience moral conflict, ethical challenges and ethical dilemmas during their career. These conflicts in association with other modifying factors such as personality traits can lead to the experience of moral distress. In a profession with known levels of occupational stress and reported mental health problems, exploring the area of moral distress and its effects on the professional wellbeing of veterinarians is important. Further studies such as developing a moral distress scale to measure this issue are needed in order to evaluate the incidence of this problem in veterinary professionals. Furthermore, assessing a possible relationship between moral distress, mental illness and attrition in veterinarians would be useful in developing intervention strategies to minimise the experience of moral distress and its associated negative consequences in veterinarians.

Physical Therapists' Ethical Dilemmas in Treatment, Coding, and Billing for Rehabilitation Services in Skilled Nursing Facilities: A Mixed-Method Pilot Study

OBJECTIVES

Reimbursement in skilled nursing facilities (SNFs) is driven by the number of minutes a patient receives rehabilitation. Physical therapists' (PTs) clinical decisions in evaluation and appropriate treatment of patients drive the dosing of rehabilitation services. Many times these 2 dynamics clash. The purpose of this study was to determine how PTs in SNFs viewed their ethical work environment, what primary issues drove their views, and what potential solutions were identified for the issues.

DESIGN

This was a mixed-methods, cross-sectional survey study.

SETTING AND PARTICIPANTS

An organizational ethics survey along with 2 open-ended questions were sent to a random sample of 1200 PTs in the state of Georgia; 340 surveys were returned, and the respondents were categorized into 9 typical PT work settings. Twenty eight participants (8.2%) reported they worked in SNFs.

MEASURES

The Ethics Environment Questionnaire was the quantitative measurement tool used for the study. In addition, 2 open-ended questions were asked regarding ethical concerns and possible solutions to those concerns.

RESULTS

Of the 9 workplace settings, therapists working in SNFs had the lowest perceptions of ethical work environment. They were also the only group that scored below the survey cut-off point for positive ethical work environment. Their primary concerns were overutilization issues, productivity standards, and billing and coding issues. The 2 primary themes regarding solutions were allowing PTs to be autonomous in their decision making and decreasing productivity standards.

CONCLUSIONS/IMPLICATIONS

The current Medicare reimbursement system rewards quantity of rehabilitation over quality. PTs are trained to deliver quality care that is dosed appropriately, and this may conflict with organizational objectives. The primary implication in this study is that clinicians and administrators should engage more in open, honest dialogue on how to share responsibility and balance organizational goals with clinical ethics.

A survey of moral distress in staff working in intensive care in the UK

Elevated rates of burnout and post-traumatic stress have been found in staff working in critical care settings, but the aspect of moral distress has been harder to quantify until a recent revision of a scale previously designed for nurses, was adapted for use with a range of health professionals, including physicians. In this cross-sectional survey, n = 171 nurses and physicians working in intensive care in the United Kingdom completed the Moral Distress Scale-Revised in relation to their experiences at work. Mean (SD) Moral Distress Scale-Revised score was 70.2 (39.6). Significant associations were found with female gender (female 74.1 (40.2) vs. male 55.5 (33.8), p = 0.010); depression (r = 0.165, p = 0.035) and with intention to leave job (considering leaving 85.5 (42.4) vs. not considering leaving 67.2 (38.6), p = 0.040). These results highlight the importance of considering the moral impact of work-related issues when addressing staff wellbeing in critical care settings.

Ethical conflicts and their characteristics among critical care nurses

INTRODUCTION

Ethical conflict is a phenomenon that has been under study over the last three decades, especially the types moral dilemma and moral distress in the field of nursing care. However, ethical problems and their idiosyncrasies need to be further explored.

AIM

The objectives of this study were, first, to obtain a transcultural Portuguese-language adaptation and validation of the Ethical Conflict Nursing Questionnaire-Critical Care Version and, second, to analyse Portuguese critical care nurses' level of exposure to ethical conflict and its characteristics.

METHODS

A cross-cultural validation and descriptive, prospective and correlational study. The sample was made for 184 critical care nurses in 2016.

ETHICAL CONSIDERATIONS

The study was authorised by Bioethics Commission of the University of Barcelona, the Associaçâo de Apoio ao Serviço de Cuidados Intensivos do Centro Hospitalar do Porto and the Sociedade Portuguesa de Enfermagem de Saúde Mental.

FINDINGS

The Portuguese version of the Ethical Conflict Nursing Questionnaire-Critical Care Version was a valid and reliable instrument to measure exposure to conflict. Moral outrage was the most common type of conflict. The most problematic situations were the ineffectiveness of analgesic treatments, the administration of treatments considered futile and the mismanagement of resources.

Moral distress in intensive care unit personnel is not consistently associated with adverse medication events and other adverse events

PURPOSE

To examine the association between moral distress in ICU personnel, and medication errors and adverse events, and other adverse events.

MATERIALS AND METHODS

In 13 ICUs, we measured moral distress once in all ICU staff, and incidence of five explicity-defined adverse safety events over 2 years. In 10 of the ICUs, pharmacists tabulated medication errors and adverse events during 1 day in the 2-year period. Average moral distress scores for each professional group were correlated with each safety measure.

RESULTS

In the pharmacy study, there were almost no significant correlations between moral distress and measures of medication safety. However, higher moral distress in nurses was associated with more interceptions of near misses per administration error (r = 0.68, p = 0.04), and higher moral distress in physicians was associated with more incorrect measurements for medication monitoring per recommended action for monitoring (r = 0.68, p = 0.03). For the other adverse events, the only significant association was a positive association between moral distress in physicians and bleeding while on anticoagulants (OR: 1.1; 95% CI: 1.0-1.3).

CONCLUSION

Moral distress in ICU personnel is generally not associated with medication errors or adverse events, or other adverse events, but it may be associated with both hyper-vigilance and distraction.

Influence of nurse's involvement on practices during end-of-life decisions within stroke units

OBJECTIVES

Decision-making processes concerning end-of-life decisions are not well understood for patients admitted into stroke units with severe stroke. To assess the influence of nurses on the medical perspectives and approaches that lead to withholding and/or withdrawing treatments related to end-of-life (EOL) decisions.

PATIENTS AND METHODS

This secondary analysis nested within the TELOS French national survey was based on a physicians' self-report questionnaire and on a I-Score which was linked to nurses' involvement. Physician's responses were evaluated to assess the potential influence of nurse's involvement on physician's choices during an end-of-life decision.

RESULTS

Among the 120 questionnaires analyzed, end-of-life decisions were more often made during a round-table discussion (58% vs. 35%, p = 0.004) when physicians declare to involve nurses in the decision process. Neurologists involved with nurses in decision making were more likely to withhold a treatment (98% vs. 88%, p = 0.04), to withdraw artificial feeding and hydration (59% vs. 39%, p = 0.04), and more frequently prescribed analgesics and hypnotics at a potentially lethal dose (70% vs. 48%, p = 0.03).

CONCLUSION

The involvement of nurses during end-of-life decisions for patients with acute stroke in stroke units seemed to influence neurologists' intensivist practices and behaviors. Nurses supported the physicians' decisions related to forgoing life sustaining treatment for patients with acute stroke and may positively impact on the family's choice to participate in end-of-life decisions.

The development and validation of the Ethical Sensitivity Questionnaire for Nursing Students

BACKGROUND

Recent advances in medicine and an increasingly demanding healthcare environment are causing various complicated ethical problems. Nursing students need to prepare to deal with ethical issues in their future roles. Ethical sensitivity is a key aspect of the ethical decision-making process; however, there is no scale to measure nursing students' ethical sensitivity. Therefore, we developed a scale and verified its reliability and validity.

METHODS

The Ethical Sensitivity Questionnaire for Nursing Students (ESQ-NS) was developed in three phases. First, questionnaire items were formulated after a literature review and interviews with nursing students. Next, its face and content validity were examined by an expert panel and piloted among nursing university graduates. Then, a final draft questionnaire survey was administered to nursing university students from 10 Japanese universities in 2015 and an exploratory factor analysis was performed. Criteria-related relevance was examined to compare established scales (i.e. the Japanese version of the Moral Sensitivity Test (JMST) and the Japanese version of the revised Moral Sensitivity Questionnaire (JMSQ)) using single regression analysis. A second questionnaire survey was conducted in one of the 10 universities to examine reliability.

RESULTS

Initially, 48 items including ethical conflict in clinical nursing practice were formulated, and 47 items were approved by the expert panel. Five-hundred and twenty-eight nursing students responded to the final draft questionnaire. Participants' mean age was 20.4 (standard deviation = 3.1) years. The questionnaire was reduced to 13 items and three factor structures were determined by exploratory factor analysis: 'respect for individuals', 'distributive justice', and 'maintaining patients' confidentiality'. The Cronbach's alpha values for items in each domain ranged from 0.77-0.81, and the Cronbach's alpha for the entire ESQ-NS was 0.82. The ESQ-NS was significantly associated with specific domains: ‛Judgment of the care conflict' from the JMST and 'Sense of Moral Burden' from the JMSQ. Pearson's correlation coefficient of the ESQ-NS between the first and second survey was 0.42 (p < .01).

CONCLUSIONS

The EAQ-NS, which was developed to evaluate the ethical susceptibility of nursing students, showed good validity, internal consistency, and reliability. This questionnaire can be used to evaluate nursing students' ethics education by self-evaluation.

Pediatric Oncology Nurses' Experiences With Prognosis-Related Communication

OBJECTIVES

To examine nurses' experiences of prognosis-related communication (PRC) with parents of children with cancer.

SAMPLE & SETTING

Cross-sectional, correlational study in the pediatric oncology setting involving 316 members of the Association of Pediatric Hematology/Oncology Nurses.

METHODS & VARIABLES

Online survey regarding individual nurse factors, PRC, interprofessional collaboration, moral distress, and perceived quality of care.

RESULTS

Nurses strongly agreed that prognostic disclosure is critical for decision making, but they are challenged in determining their role. Nurses with more years of experience and training in PRC, those working in an outpatient setting, and those with higher levels of nurse-physician collaboration reported more positive experiences with PRC. Positive experiences with PRC and collaboration were significantly associated with higher nurse-perceived quality of care and reduced nurse moral distress.

IMPLICATIONS FOR NURSING

Nurses should work to be active participants in the process of PRC by collaborating with physician colleagues. When nurses sense that prognostic discussions have been absent or unclear, they should feel confident in approaching physician colleagues to ensure parent understanding and satisfaction with communication.

What is 'moral distress'? A narrative synthesis of the literature

AIMS

The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress.

BACKGROUND

Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon.

DESIGN

Systematic literature review and narrative synthesis (November 2015-March 2016).

DATA SOURCES

Ovid MEDLINE® In-Process & Other Non-Indexed Citations 1946-Present, PsycINFO® 1967-Present, CINAHL® Plus 1937-Present, EMBASE 1974-24 February 2016, British Nursing Index 1994-Present, Social Care Online, Social Policy and Practice Database (1890-Present), ERIC (EBSCO) 1966-Present and Education Abstracts.

REVIEW METHODS

Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis.

RESULTS

In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity.

CONCLUSION

We suggest the combination of (1) the experience of a moral event, (2) the experience of 'psychological distress' and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress.

Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals

BACKGROUND

As ongoing research explores the impact of moral distress on health care professionals (HCPs) and organizations and seeks to develop effective interventions, valid and reliable instruments to measure moral distress are needed. This article describes the development and testing of a revision of the widely used Moral Distress Scale-Revised (MDS-R) to measure moral distress.

METHODS

We revised the MDS-R by evaluating the combined data from 22 previous studies, assessing 301 write-in items and 209 root causes identified through moral distress consultation, and reviewing 14 recent publications from various professions in which root causes were described. The revised 27-item scale, the Measure of Moral Distress for Healthcare Professionals (MMD-HP), is usable by all HCPs in adult and pediatric critical, acute, or long-term acute care settings. We then assessed the reliability of the MMD-HP and evaluated construct validity via hypothesis testing. The MMD-HP, Hospital Ethical Climate Survey (HECS), and a demographic survey were distributed electronically via Qualtrics to nurses, physicians, and other health care professionals at two academic medical centers over a 3-week period.

RESULTS

In total, 653 surveys were included in the final analysis. The MMD-HP demonstrated good reliability. The four hypotheses were supported: (1) MMD-HP scores were higher for nurses (M 112.3, SD 73.2) than for physicians (M 96.3, SD 54.7, p = 0.023). (2) MMD-HP scores were higher for those considering leaving their position (M 168.4, SD 75.8) than for those not considering leaving (M 94.3, SD 61.2, p < 0.001). (3) The MMD-HP was negatively correlated with the HECS (r = -0.55, p < 0.001). (4) An exploratory factor analysis revealed a four-factor structure, reflective of patient, unit, and system levels of moral distress.

CONCLUSIONS

The MMD-HP represents the most currently understood causes of moral distress. Because the instrument behaves as would be predicted, we recommend that the MMD-HP replace the MDS-R.

Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses

Context:

Providing nonbeneficial care at the end of life and delays in initiating comfort care have been associated with provider and nurse moral distress.

Objective:

Evaluate provider and nurse moral distress when using a comfort care order set and attitudes about timing of initiating comfort care for hospitalized patients.

Methods:

Cross-sectional survey of providers (physicians, nurse practitioners, and physician assistants) and nurses at 2 large academic hospitals in 2015. Providers and nurses were surveyed about their experiences providing comfort care in an inpatient setting.

Results:

Two hundred five nurse and 124 provider surveys were analyzed. A greater proportion of nurses compared to providers reported experiencing moral distress “some, most, or all of the time” when using the comfort care order set (40.5% and 19.4%, respectively, P = .002). Over 60% of nurses and providers reported comfort care was generally started too late in a patient’s course, with physician trainees (81.4%), as well as providers (80.9%) and nurses (84.0%) < 5 years from graduating professional school most likely to report that comfort care is generally started too late.

Conclusions:

The majority of providers and nurses reported that comfort care was started too late in a patient’s course. Nurses experienced higher levels of moral distress than providers when caring for patients using a comfort care order set. Further research is needed to determine what is driving this moral distress in order to tailor interventions for nurses and providers.

Coping with moral distress - The experiences of intensive care nurses: An interpretive descriptive study

BACKGROUND

Over the last three decades, there has been a growing body of literature that has described moral distress as a prominent issue that negatively affects intensive care nurses. Yet, little focus has been given to how intensive care nurses cope and continue in their practice despite being exposed to moral distress.

OBJECTIVE

To describe intensive care nurses' experiences of coping with moral distress.

RESEARCH METHODS/SETTING

A qualitative design using an interpretative descriptive approach. Semi-structured interviews were conducted with seven intensive care nurses.

FINDINGS

The shared experience of coping with moral distress was explicated through the overarching theme of being Like Grass in the Wind. Four major themes emerged: Going Against What I Think is Best, Moral Distress - It's Just Inherent in Our Job, It Just Felt Awful, and Dealing with It. The findings also reflected actions associated with turning towards or turning away from morally distressing situations.

CONCLUSION

By developing coping strategies such as seeking social support, nurses can move forward in their practice and meaningfully engage with patients and families experiencing critical illness. When successful coping is not attained, nurses are at risk of becoming morally disengaged within their practice.

[Nonbeneficial care-a burden for clinicians and relatives]

BACKGROUND

Ethically demanding decisions in intensive care as well as the perception of nonbeneficial care can be a burden for clinicians and patients' relatives.

OBJECTIVES

An overview of prevalence, causes, and consequences of perceived nonbeneficial care and possible interventions is provided.

MATERIALS AND METHODS

Narrative review.

RESULTS AND CONCLUSIONS

The perception of nonbeneficial care is a subjective moral judgement. Almost every ICU clinician regularly perceives nonbeneficial care. There is clear evidence that perceived nonbeneficial care is associated with burnout of clinicians and intention to leave the job. For relatives being involved in end-of-life decisions is of particular burden. Clinicians often state that relatives' whishes are the reason for nonbeneficial life-sustaining treatment. A good ethical climate as well as good nurse-physician collaboration are associated with less perception of nonbeneficial care and shorter time to therapy limitations. Structured communication to plan therapy involving relatives might reduce nonbeneficial care and together with supporting interventions reduce staff burnout. Improving communication by consultants in charge has been shown to reduce the burden of relatives. In future, co-treating surgeons must be more strongly involved in interventions.

The ethical climate in paediatric oncology-A national cross-sectional survey of health-care personnel

Objective

To describe health‐care personnel's (HCP's) perceptions of the ethical climate at their workplace in paediatric oncology.

Methods

A cross‐sectional survey was conducted using the Swedish version of the shortened Hospital Ethical Climate Survey (HECS‐S). HCP at all six paediatric oncology centres (POCs) in Sweden were invited to participate. Analysis included descriptive statistics, the Mann‐Whitney U test (differences between groups) and Spearman's rank correlation. Informed consent was assumed when the respondents returned the survey.

Results

A high response rate was achieved as 278 HCP answered the questionnaire. Medical doctors perceived the ethical climate to be more positive than registered nurses and nursing assistants. At the POC with the significantly lowest values concerning immediate manager, no significant correlation with the other items was found. At the POC with the poorest ethical climate, HCP also had the lowest perception of the possibility of practicing ethically good care.

Conclusions

Differences between centres and professional groups have been demonstrated. A negative perception of the immediate manager does not necessarily mean that the ethical climate is poor, but the manager's ability to provide the conditions for an open dialogue within the health‐care team is key to achieving an ethical climate.

The ethical conundrum: Conflicting advocacy positions in advanced heart failure therapy

It is estimated that nearly 6.5 million Americans over the age of 20 suffer from heart failure. Heart failure is the leading cause of hospitalization in patients over 65 years of age, and carries with it a 5-year mortality of nearly 50%. Despite advances in medical therapy, treatment for medically refractory end-stage, advanced heart failure is limited to heart transplant, mechanical circulatory support (MCS), or palliative care only. Patient selection in advanced heart failure (AHF) therapy is complex. Not only are the patients medically complicated, but providers are biased by their individual and collective experience with similar and dissimilar patients. Clinicians caring for AHF patients balance competing clinical and ethical demands, which appropriately leads to professional debate and disagreement. These debates are constructive because they clarify ethical and professional commitments and help to ensure fair and equitable treatment of AHF patients.

Moral Distress in the Pediatric Intensive Care Unit: An Italian Study

Introduction: There is paucity of data within the Italian context regarding moral distress in intensive pediatric settings. The aim of the present study was to assess the frequency, intensity, and level of moral distress experienced by nurses working in a sample of pediatric intensive care units (PICUs). Materials and Methods: A cross-sectional questionnaire survey was conducted in eight PICUs from five northern Italian regions in a convenience sample of 136 nurses. Moral distress was evaluated using the modified Italian version of the Moral Distress Scale Neonatal-Pediatric Version (MDSNPV). Each item was scored in terms of frequency and intensity on a five-point Likert scale, ranging from 0 to 4. The total frequency and intensity scores for all the 21 clinical items were comprised between 0 and 84. For each item, the level of moral distress was derived by multiplying the frequency score by the intensity score and quantified with a score ranging from 0 to 16. The total score of the moral distress level for the 21 items ranged from 0 to 336. Results: The mean total scores for the frequency, intensity and level of moral distress were 24.1 ± 10.4, 36.2 ± 18.6, and 57.7 ± 37.1, respectively. The clinical situations identified as the major causes of moral distress among nurses in the present study involved end-of-life care and resuscitation. At multivariate logistic regression analysis, number of deaths occurring in PICUs, having children and intention to leave work due to moral distress resulted to be independently associated with a higher total moral distress level. Conclusions: The results of the present study contribute to the understanding of moral distress experience in acute pediatric care settings, including the clinical situations associated with a higher moral distress level, and highlight the importance of sharing thoughts, feelings and information within the multidisciplinary health care professional team for effective shared decision making, particularly in situations involving end-of-life care and resuscitation.

Moral distress of undergraduate nursing students in community health nursing

BACKGROUND

Nurses exposed to community health nursing commonly encounter situations that can be morally distressing. However, most research on moral distress has focused on acute care settings and very little research has explored moral distress in a community health nursing setting especially among nursing students.

AIM

To explore the moral distress experiences encountered by undergraduate baccalaureate nursing students in community health nursing.

RESEARCH DESIGN

A descriptive qualitative design was employed to explore the community health nursing experiences of the nursing students that led them to have moral distress.

PARTICIPANTS AND RESEARCH CONTEXT

The study included 14 senior nursing students who had their course in Community Health Nursing in their sophomore year and stayed in the partner communities in their junior year for 6 and 3 weeks during their senior year.

ETHICAL CONSIDERATIONS

Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants.

FINDINGS

Nursing students are vulnerable and likely to experience moral distress when faced with ethical dilemmas. They encounter numerous situations which make them question their own values and ideals and those of that around them. Findings of the study surfaced three central themes which included moral distress emanating from the unprofessional behavior of some healthcare workers, the resulting sense of powerlessness, and the differing values and mindsets of the people they serve in the community.

CONCLUSION

This study provides educators a glimpse of the morally distressing situations that often occurs in the community setting. It suggests the importance of raising awareness and understanding of these situations to assist nursing students to prepare themselves to the "real world," where the ideals they have will be constantly challenged and tested.

Difficult decisions in pediatric practice and moral distress in the intensive care unit

In an ethical dilemma, there is always an option that can be identified as the best one to be chosen. When it is impossible to adopt such option, the situation can lead professionals to experience moral distress. This review aims to define the issue of moral distress and propose coping strategies. Systematic searches in the MEDLINE/PubMed and SciELO databases were conducted using the keywords "moral distress" and "moral suffering" in articles published between 2000 and 2017. This review was non-exhaustive and contextual, with a focus on definitions, etiologies and methods of resolution for moral distress. In the daily practice of intensive care, moral distress was commonly related to the prolongation of patients' suffering and feelings of helplessness, as well as difficulties in communication among team members. Coping strategies for moral distress included organizational, personal and administrative actions. Actions such as workload management, mutual support among professionals and the development of techniques to cultivate open communication, reflection and questioning within the multidisciplinary team were identified. In clinical practice, health professionals need to be recognized as moral agents, and the development of moral courage was considered helpful to overcome ethical dilemmas and interprofessional conflicts. Both in pediatric and adult intensive care, professionals are challenged by questions about their practice, and they may experience moral distress. This suffering can be minimized and solved by understanding that the focus is always on the patient and acting with moral courage and good communication in an environment of mutual respect.

Nurses Providing End-of-Life Care for Infants and Their Families in the NICU: A Review of the Literature

BACKGROUND

Nurses working in the neonatal intensive care unit (NICU) who care for dying infants and their families say they do not necessarily have the expertise or the specific training to provide quality end-of-life-care (EOLC).

PURPOSE

The purpose of this review was to critically appraise the existing qualitative literature regarding nurses' experiences when caring for infants during end of life in the NICU and to identify barriers and enablers to provide quality EOLC.

SEARCH STRATEGY

A literature search was conducted using CINAHL and OVID databases. Studies that explored nurses' experiences when caring for infants who were dying or when lifesaving care was withdrawn were retrieved and 15 studies were thematically analyzed.

RESULTS

Five major themes emerged: advocating for the dying infant, building close relationships with the family, providing an appropriate care environment, nurses' emotional responses to dying or death, and professional inadequacy in EOLC.

IMPLICATIONS FOR PRACTICE

Nurses face multiple challenges when providing EOLC including moral dilemmas and feelings of professional inadequacy. Avoidance was a common strategy used by nurses to cope with the stress associated with EOLC. Managers can foster quality EOLC by implementing education sessions about infant mortality, EOLC, advocacy, team communication, and self-care practices.

IMPLICATIONS FOR RESEARCH

Research could evaluate the effectiveness of EOLC education sessions to build nurses' competence and confidence in advocacy and EOLC clinical skills.

Rethinking moral distress: conceptual demands for a troubling phenomenon affecting health care professionals

Recent medical and bioethics literature shows a growing concern for practitioners' emotional experience and the ethical environment in the workplace. Moral distress, in particular, is often said to result from the difficult decisions made and the troubling situations regularly encountered in health care contexts. It has been identified as a leading cause of professional dissatisfaction and burnout, which, in turn, contribute to inadequate attention and increased pain for patients. Given the natural desire to avoid these negative effects, it seems to most authors that systematic efforts should be made to drastically reduce moral distress, if not altogether eliminate it from the lives of vulnerable practitioners. Such efforts, however, may be problematic, as moral distress is not adequately understood, nor is there agreement among the leading accounts regarding how to conceptualize the experience. With this article I make clear what a robust account of moral distress should be able to explain and how the most common notions in the existing literature leave significant explanatory gaps. I present several cases of interest and, with careful reflection upon their distinguishing features, I establish important desiderata for an explanatorily satisfying account. With these fundamental demands left unsatisfied by the leading accounts, we see the persisting need for a conception of moral distress that can capture and delimit the range of cases of interest.

Moral distress is associated with general workplace distress in intensive care unit personnel

PURPOSE

To assess the association between moral distress and general workplace distress in intensive care unit (ICU) personnel.

MATERIALS AND METHODS

We administered the Moral Distress Scale Revised and the Job Content Questionnaire to all clinicians (870 nurses, 68 physicians, 452 other health professionals) in 13 ICUs (3 tertiary, 3 large community, 7 small community) in British Columbia, Canada. We used mixed effects regression, treating ICUs as clusters, to examine the association between the Moral Distress Score and each Job Content Questionnaire scale (decision latitude, psychological stressors, social support, psychological strain) after adjusting for age, sex, and years of experience of respondents; separate analyses were done for each profession.

RESULTS

Overall response rate was 45%. Nurses and other health professionals had higher moral distress scores than physicians, but there were no differences in general workplace distress scores among professional groups. After adjustment for demographic characteristics, higher moral distress in nurses was associated with lower decision latitude and social support, and with higher psychological stressors and psychological strain. For physicians and other professionals, these relationships were similar.

CONCLUSIONS

Moral distress is associated with general workplace distress in ICU personnel. Interventions that ameliorate either type of distress may also ameliorate the other.

Moral distress in paediatric oncology: Contributing factors and group differences

BACKGROUND

Providing oncological care to children is demanding and ethical issues concerning what is best for the child can contribute to moral distress.

OBJECTIVES

To explore healthcare professionals' experiences of situations that generate moral distress in Swedish paediatric oncology.

RESEARCH DESIGN

In this national study, data collection was conducted using the Swedish Moral Distress Scale-Revised. The data analysis included descriptive statistics and non-parametric analysis of differences between groups.

PARTICIPANTS AND RESEARCH CONTEXT

Healthcare professionals at all paediatric oncology centres in Sweden were invited to participate. A total of 278 healthcare professionals participated. The response rate was 89%.

ETHICAL CONSIDERATIONS

In its advisory statement, the Regional Ethical Review Board decided that the study was of such a nature that the legislation concerning ethical reviews was not applicable. All participants received written information about the aim of the study and confidentiality. Participants demonstrated their consent by returning the survey.

FINDINGS

The two situations with the highest moral distress scores concerned lack of competence and continuity of personnel. All professional groups reported high levels of disturbance. Nurses rated significantly higher frequencies and higher total Moral Distress Scale scores compared to medical doctors and nursing assistants.

DISCUSSION

Lack of competence and continuity, as the two most morally distressing situations, confirms the findings of studies from other countries, where inadequate staffing was reported as being among the top five morally distressing situations. The levels of total Moral Distress Scale scores were more similar to those reported in intensive care units than in other paediatric care settings.

CONCLUSION

The two most morally distressing situations, lack of competence and continuity, are both organisational in nature. Thus, clinical ethics support services need to be combined with organisational improvements in order to reduce moral distress, thereby maintaining job satisfaction, preventing a high turnover of staff and ensuring the quality of care.

The effectiveness of narrative writing on the moral distress of intensive care nurses

BACKGROUND

Nursing is a profession that has always been accompanied with common ethical concerns. There are some evidences which indicate that narrative writing on traumatic experiences may improve an individual's emotional health.

OBJECTIVE

This study aimed to determine the effectiveness of narrative writing on moral distress of nurses working in intensive care unit.

RESEARCH DESIGN

This study was a clinical trial with pre- and post-test design. The frequency and intensity of moral distress was measured by a valid and reliable questionnaire (Corely) at baseline and after 8 weeks. The intervention group was asked to write about their deepest emotions and stressful experiences in the intensive care unit for 8 weeks.

PARTICIPANTS AND RESEARCH CONTEXT

Using consensus sampling, 120 nurses of intensive care unit and neonatal intensive care unit of the teaching hospitals (in Iran) were invited to and were randomly allocated into the intervention and control groups.

ETHICAL CONSIDERATIONS

Participation was voluntary, data were anonymized, and the confidentiality of the participating nurses and their institutions maintained. The ethical approval was obtained from an IRB or research ethics committee.

FINDINGS

In total, 106 nurses completed the trial consisting of 87.75% females. The mean work experience of nurses in the intervention and control groups was 7.21 ± 4.96 and 8.28 ± 5.45 years, respectively. Independent t-test showed no statistical difference neither in the intensity of moral distress (P = 0.8), nor in its frequency (P = 0.5) between the two groups.

DISCUSSION

As nurses constantly face ethical tensions, moral distress is a phenomenon that results from the different situations of critical care units. Their concern about receiving negative feedback from the managerial level may have influenced the outcome of the intervention.

CONCLUSION

Narratives writing by the nurses showed no effect on reducing the intensity and frequency of moral distress. It seems that due to the intensity of moral distress in clinical settings, we need to test variety solutions to reduce the problem.

"What if she was your mother?" Toward better responses

Critical care physicians may hear a surrogate decision-maker ask, "What would you do if she was your mother?" or "What if your father was this sick?" These kinds of questions ask more of the critical care physician than the surrogate might realize. There are deep-seated ethical, professional, and personal complexities that can challenge critical care physicians to answer these questions with honesty. This essay offers practical guidance for critical care physicians who aim to respond to such queries with honesty and beneficence. We discuss a variety of motivations that can accompany this unique kind of question from a surrogate. The surrogate may be seeking moral guidance-the true question being, "What should I do?" We offer a number of questions that the critical care physician might ask of the surrogate in order to attend to both the surrogate's moral dilemma and the patient's values and preferences for medical interventions. We also offer a number of questions to promote contemplation of these issues by the critical care physician herself. We argue that until the critical care physician: discovers the surrogate's motivation, connects this motivation to patient preferences, and asks herself important questions regarding death and dying, the physician's responses will not adequately attend to the issues prompted by such questions.

Seeing the Patient and Family Through: Nurses and Physicians Experiences With Withdrawal of Life-Sustaining Therapy in the ICU

Withdrawal of life-sustaining therapy at the end of life is a complex phenomenon. Intensive care nurses and physicians are faced with caring for patients and supporting families, as these difficult decisions are made. The purpose of this study was to explore and describe the experience of critical care nurses and physicians participating in the process of withdrawal of life-sustaining therapy. A hermeneutic phenomenological approach was used to guide this qualitative investigation. Interviews were conducted with critical care nurses and physicians from 2 medical centers. An inductive approach to data analysis was used to understand similarities between the nurses and the physicians’ experiences. Methodological rigor was established, and data saturation was achieved. The main categories that were inductively derived from the data analysis included from novice to expert, ensuring ethical care, uncertainty to certainty, facilitating the process, and preparing and supporting families. The categories aided in understanding the experiences of nurses and physicians, as they worked individually and together to see patients and families through the entire illness experience, withdrawal of life-sustaining therapy decision-making process and dying process. Understanding the perspectives of health-care providers involved in the withdrawal of life-sustaining therapy process will help other health-care providers who are striving to provide quality care to the dying and to their families.

Applying a Balm: Medicating the Patient to Treat the (Moral) Distress of Caregivers

Moral distress occurs when a nurse knows the right action but is impeded from taking that right action because of institutional constraints. Caring for patients who are dying might evoke distress, including moral distress. The distress from a difficult clinical situation is likely to permeate other areas of practice. In this article, 2 cases are used as a means to distinguish moral distress from other distress arising from clinical situations. Opportunities to alleviate distress include increasing knowledge, improved communication, enhanced collaboration, and development of institutional supports.

Parental Moral Distress and Moral Schism in the Neonatal ICU

Ethical dilemmas in critical care may cause healthcare practitioners to experience moral distress: incoherence between what one believes to be best and what occurs. Given that paediatric decision-making typically involves parents, we propose that parents can also experience moral distress when faced with making value-laden decisions in the neonatal intensive care unit. We propose a new concept-that parents may experience "moral schism"-a genuine uncertainty regarding a value-based decision that is accompanied by emotional distress. Schism, unlike moral distress, is not caused by barriers to making and executing a decision that is deemed to be best by the decision-makers but rather an encounter of significant internal struggle. We explore factors that appear to contribute to both moral distress and "moral schism" for parents: the degree of available support, a sense of coherence of the situation, and a sense of responsibility. We propose that moral schism is an underappreciated concept that needs to be explicated and may be more prevalent than moral distress when exploring decision-making experiences for parents. We also suggest actions of healthcare providers that may help minimize parental "moral schism" and moral distress.

Development and validation of the Moral Distress in Dementia Care Survey instrument

AIMS

To report on the development and validation of the Moral Distress in Dementia Care Survey instrument.

BACKGROUND

Despite growing awareness of moral distress among nurses, little is known about the moral distress experiences of nursing staff in dementia care settings. To address this gap, our research team developed a tool for measuring the frequency, severity and effects of moral distress in nursing staff working in dementia care.

DESIGN

The research team employed an exploratory sequential mixed method design to generate items for the moral distress questionnaire. Data were collected between January 2013 - June 2014. In this paper, we report on the development and validation of the Moral Distress in Dementia Care Survey instrument.

METHODS

The Moral Distress in Dementia Care Survey instrument was piloted with a portion of the target population prior to a broader implementation. Appropriate statistical analyses and psychometric testing were completed.

RESULTS

The team collected 389 completed surveys from registered nurses, licensed practical nurses and healthcare aides, representing a 43.6% response rate across 23 sites. The Moral Distress in Dementia Care Survey emerged as a reliable and valid instrument to measure the frequency, severity and effects of moral distress for nursing staff in dementia care settings. The relative value of the Moral Distress in Dementia Care Survey as a measurement instrument was superseded by its clinical relevance for dementia care staff.

CONCLUSION

The Moral Distress in Dementia Care Survey is a potentially useful tool for estimating the frequency, severity and effects of moral distress in nursing staff working in dementia care settings and for the evaluation of measures taken to mitigate moral distress.

Association of Perceived Futile or Potentially Inappropriate Care With Burnout and Thoughts of Quitting Among Health-Care Providers

BACKGROUND

Futile or potentially inappropriate care (futile/PIC) has been suggested as a factor contributing to clinician well-being; however, little is known about this association.

OBJECTIVE

To determine whether futile/PIC provision is associated with measures of clinician well-being.

DESIGN

Cross-sectional, self-administered, online questionnaire.

SETTING

Two New York City Hospitals.

PARTICIPANTS

Attending physicians, residents, nurses, and physician assistants in the fields of internal medicine, surgery, neurology, or intensive care.

EXPOSURE(S)

Provision of perceived futile/PIC.

MEASUREMENTS

Main outcomes included (1) clinician burnout, measured using the Physician Worklife Study screen; (2) clinician depression, measured using the Patient Health Questionnaire; and (3) intention to quit, measured using questions assessing thoughts of quitting and how seriously it is being considered.

RESULTS

Of 1784 clinicians who received surveys, 349 participated. Across all clinicians, 91% reported that they either had or had possibly provided futile/PIC to a patient. Overall, 43.4% of clinicians screened positive for burnout syndrome, 7.8% screened positive for depression, and 35.5% reported thoughts of leaving their job as a result of futile/PIC. The amount of perceived futile/PIC provided was associated with burnout (odds ratio [OR] 3.8 [16-30 patients vs 1-2 patients]; 95% confidence interval [CI]: 1.1-12.8) and having thoughts of quitting (OR, 7.4 [16-30 patients vs 1-2 patients]; 95% CI: 2.0-27), independent of depression, position, department, and the number of dying patients cared for.

CONCLUSIONS

A large majority of clinicians report providing futile/PIC, and such care is associated with measures of clinician well-being, including burnout and intention to quit.

Psychometric Properties of the Hospital Ethical Climate Survey: A Cross-Sectional Study in Greek and Cypriot Cancer Care Settings

Background and Purpose:

Ethical climate provides the context in which ethical behavior and decision-making occur. To test the psychometric properties of the Greek version of the Hospital Ethical Climate Survey (HECS) in cancer care settings.

Methods:

This was a cross-sectional study with 235 cancer nurses. Principal component analysis (PCA) and confirmatory factor analysis (CFA) were examined. Reliability was investigated with Cronbach’s coefficient α.

Results:

Cronbach’s α was 0.86 for the HECS total and ranged from 0.71 to 0.85 for the five subscales. PCA revealed that five components accounted for 61.09% of the variance which were comparable to those produced in the original validation study. The CFA with the five factors identified, produced a model with a good fit.

Conclusion:

The Greek version of the HECS is valid and reliable for use within the cancer care context.

Relationships Among Palliative Care, Ethical Climate, Empowerment, and Moral Distress in Intensive Care Unit Nurses

BACKGROUND

Intensive care unit nurses experience moral distress when they feel unable to deliver ethically appropriate care to patients. Moral distress is associated with nurse burnout and patient care avoidance.

OBJECTIVES

To evaluate relationships among moral distress, empowerment, ethical climate, and access to palliative care in the intensive care unit.

METHODS

Intensive care unit nurses in a national database were recruited to complete an online survey based on the Moral Distress Scale-Revised, Psychological Empowerment Index, Hospital Ethical Climate Survey, and a palliative care delivery questionnaire. Descriptive, correlational, and regression analyses were performed.

RESULTS

Of 288 initiated surveys, 238 were completed. Participants were nationally representative of nurses by age, years of experience, and geographical region. Most were white and female and had a bachelor's degree. The mean moral distress score was moderately high, and correlations were found with empowerment (r = -0.145; P = .02) and ethical climate scores (r = -0.354; P < .001). Relationships between moral distress and empowerment scores and between moral distress and ethical climate scores were not affected by access to palliative care. Nurses reporting palliative care access had higher moral distress scores than those without such access. Education, ethnicity, unit size, access to full palliative care team, and ethical climate explained variance in moral distress scores.

CONCLUSIONS

Poor ethical climate, unintegrated palliative care teams, and nurse empowerment are associated with increased moral distress. The findings highlight the need to promote palliative care education and palliative care teams that are well integrated into intensive care units.

Acceptability and feasibility of an interprofessional end-of-life/palliative care educational intervention in the intensive care unit: A mixed-methods study

OBJECTIVES

This study aimed to describe a seven hour End-of-Life/Palliative Care educational intervention including online content related to symptom management, communication and decision-making capacity and an in-person group integration activity, from the perspective of the interprofessional team in terms of its acceptability and feasibility.

RESEARCH DESIGN

A mixed-methods study design was used.

SETTING AND SAMPLE

The study was conducted in a medical-surgical Intensive Care Unit in Montreal, Canada. The sample consisted of 27 clinicians of the Intensive Care Unit interprofessional team who completed the End-of-Life/Palliative Care educational intervention, and participated in focus groups and completed a self-administered questionnaire.

MAIN OUTCOME MEASURES

The main outcomes were the acceptability and feasibility of the educational intervention.

FINDINGS

The intervention was perceived to be appropriate and suitable in providing clinicians with knowledge and skills in symptom management and communication through self-reflection and self-evaluation, provision of assessment tools and promotion of interprofessional teamwork. The online format was more feasible, but the in-person group activity was key for the integration of knowledge and the promotion of interprofessional discussions.

CONCLUSION

Findings suggest that an interprofessional educational intervention integrating on-line content with in-person training has the potential to support clinicians in providing quality End-of-Life/Palliative Care in the Intensive Care Unit.

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose

Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown.

Methods

In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis.

Results

Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former.

Conclusion

Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5231-8) contains supplementary material, which is available to authorized users.

What happens at the end of life? Using linked administrative health data to understand healthcare usage in the last year of life in New Zealand

The end of life is often associated with increased use of healthcare services. This increased use can include over-medicalisation, or over-treatment with interventions designed to cure that are likely futile in people who are dying. This is an issue with medical, ethical, and financial dimensions, and has implications for health policy, funding and the structure of care delivery. We measured the annual use of nine pre-defined public healthcare services between 1 January 2008 and 31 December 2012 by elderly New Zealanders (65-99 years old) in their last year of life and compared it with that of the cohort of elderly New Zealanders who used healthcare in the period but did not die. We used linked, encrypted unique patient identifiers to reorganise and filter records in routinely collected national healthcare utilisation and mortality administrative datasets. We found that, in New Zealand, people do seem to use more of most health services in their last year of life than those of the same age who are not in their last year of life. However, as they advance in age, particularly after the age of 90, this difference diminishes for most measures, although it is still substantial for days spent in hospital as an inpatient, and for pharmaceutical dispensings.

Validation of a moral distress instrument in nurses of primary health care

Objective:

to validate an instrument to identify situations that trigger moral distress in relation to intensity and frequency in primary health care nurses.

Method:

this is a methodological study carried out with 391 nurses of primary health care, applied to the Brazilian Scale of Moral Distress in Nurses with 57 questions. Validation for primary health care was performed through expert committee evaluation, pre-test, factorial analysis, and Cronbach’s alpha.

Results:

there were 46 questions validated divided into six constructs: Health Policies, Working Conditions, Nurse Autonomy, Professional ethics, Disrespect to patient autonomy and Work Overload. The instrument had satisfactory internal consistency, with Cronbach’s alpha 0.98 for the instrument, and between 0.96 and 0.88 for the constructs.

Conclusion:

the instrument is valid and reliable to be used in the identification of the factors that trigger moral distress in primary care nurses, providing subsidies for new research in this field of professional practice.

A Typology of Social Workers in Long-Term Care Facilities in Israel

This article explores moral distress among long-term care facility (LTCF) social workers by examining the relationships between moral distress and environmental and personal features. Based on these features, authors identified a typology of LTCF social workers and how they handle moral distress. Such a typology can assist in the identification of social workers who are in a particular need for assistance. Overall, 216 LTCF social workers took part in the study. A two-step cluster analysis was conducted to identify a typology of LTCF social workers based on features such as ethical environment, support in workplace, mastery, and resilience. The variance of the identified clusters and their associations with moral distress were examined, and four clusters of LTCF social workers were identified. The clusters varied from each other in relation to their personal and environmental features and in relation to their experience of moral distress. The article concludes with a discussion of the importance of developing programs for LTCF social workers that provide support and enhancement of personal resources and an adequate and ethical environment for practice.

Physical therapists' perception of workplace ethics in an evolving health-care delivery environment: a cross-sectional survey

Physical therapists are trained and obligated to deliver optimal health care and put patients first above all else. In the changing health-care environment, health-care organizations are grappling with controlling cost and increasing revenues. Moral distress may be created when physical therapists' desire to provide optimal care conflicts with their organization's goals to remain financially viable or profitable. Moral distress has been associated with low perception of ethical environment, professional burnout, and high turnover in organizations. This study identified groups who may be vulnerable to low perception of organizational ethical environment and identified self-reported strategies to remedy these perceptions. An ethics environment questionnaire was mailed to a random sample of 1200 physical therapists in Georgia. Respondents (n = 340) were analyzed by age, workplace setting, and position in organization. Therapists working in skilled nursing/assisted living environments scored the lowest on the questionnaire and voiced concerns regarding their ethical work environments. Owners and executives perceived their organizations to be more ethical than front-line clinicians. Respondent concerns included high productivity standards, aggressive coding/billing policies, decreased reimbursement, and increased insurance regulation. Possible solutions included more frequent communication between management and clinicians about ethics, greater professional autonomy, and increased training in business ethics and finance.

Development and content validation of a questionnaire to assess moral distress among social workers in long-term care facilities

OBJECTIVE

Despite the significance of ethical issues faced by social workers, research on moral distress among social workers has been extremely limited. The aim of the current study is to describe the development and content validation of a unique questionnaire to measure moral distress among social workers in long-term care facilities for older adults in Israel.

METHODS

The construction of the questionnaire was based on a secondary analysis of a qualitative study that addressed the moral dilemma of social workers in nursing homes in Israel. A content validation included review and evaluation by two experts, a cognitive interview with a nursing home social worker, and three focus groups of experts and the target population.

RESULTS

The initial questionnaire consisted of 25 items. After the content validation process the questionnaire in its final version, consisted of 17 items and included two scales, measuring the frequency of morally loaded events and the intensity of distress that followed them.

CONCLUSIONS

We believe that the questionnaire can contribute by broadening and deepening ethics discourse and research, with regard to social workers' obligation dilemmas and conflicts.

Cancer Patients Dying in the Intensive Care Units and Access to Palliative Care

BACKGROUND

In France, cancer has become the leading cause of death. Intensive care units (ICU) focus on survival, which may not be an appropriate setting to provide palliative care (PC) as needed by cancer patients and families.

OBJECTIVE

To describe the cancer patients who died in the ICU in 2010 in a French academic medical center.

DESIGN

Retrospective study Measurements: We reviewed medical records of all cancer patients who died in the ICU in 2010. The information collected from electronic medical records included patient sociodemographics and clinical characteristics, PC service referral, and the date of first contact with PC.

RESULTS

Among the 536 cancer patients who died in 2010, 42 (8%) died in the ICU. The cancers were hematological (21%), gastrointestinal (21%) and head and neck (21%). One patient had a PC referral versus 45% in the total population (p < 0.001) and the referral was the same day as the death. Eight (19%) patients had chemotherapy during their last month of life and 2 during the ICU hospitalization. Seventy-four per cent of patient admissions to the ICU related directly to malignancy. The mean time between diagnosis of cancer and death was 2.3 years (standard deviation, 4.4).

CONCLUSIONS

Our work highlights the need for early PC in the illness trajectory of cancer patients to prevent the transfer of dying patients to the ICU. More studies are needed to understand the decision making leading to such transfers.

Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool

Background

Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU).

Objectives

To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates.

Methods

Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups.

Results

Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner.

Conclusions

The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians’ behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.