Daniel Garros, MD Associate Professor of Pediatrics The Dossetor Health Ethics Centre & Univ. of...
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Moral Distress: Insights From Stories in the PICU Daniel Garros, MD Associate Professor of Pediatrics The Dossetor Health Ethics Centre & Univ. of Alberta, Attending Physician, PICU, Stollery Children’s Hospital Wendy Austin, RN, PhD Professor Emeritus Canada Research Chair (Relational Ethics in Health Care) 2003-2013 The Dossetor Health Ethics Centre & Univ. of Alberta Edmonton, Canada
Daniel Garros, MD Associate Professor of Pediatrics The Dossetor Health Ethics Centre & Univ. of Alberta, Attending Physician, PICU, Stollery Children’s
Daniel Garros, MD Associate Professor of Pediatrics The
Dossetor Health Ethics Centre & Univ. of Alberta, Attending
Physician, PICU, Stollery Childrens Hospital Wendy Austin, RN, PhD
Professor Emeritus Canada Research Chair ( Relational Ethics in
Health Care ) 2003-2013 The Dossetor Health Ethics Centre &
Univ. of Alberta Edmonton, Canada
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Before I realized that she was going to die, I felt justified
in doing all our little heroic things that we do, and theyre
painful things. After I knew she was going to die, I felt badly
doing those things. I felt badly that we were prolonging the pain
for her. PICU Nurse in Davies et al., 1996, p. 502.
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The pain or anguish affecting the mind, body or relationships
in response to a situation in which the person is aware of a moral
problem, acknowledges moral responsibility, and makes a moral
judgment about the correct action; yet, as a result of real or
perceived constraints, participates in perceived moral wrongdoing,
or is unable to act on ones moral choices. Nathaniel, A. (2006).
Moral Reckoning in Nursing. Western Journal of Nursing Research,
28(4), 419-438. Definition on p. 421. Nathaniel, A. (2003). A
Grounded theory of moral reckoning in nursing. West Virginia
University, p. 22. Moral Distress
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Arises when a person believes s/he knows the right thing to do
But is unable to act on ones moral choices, due to: Internal
(personal) constraints Or because of external (contextual)
barriers
May be an expression of sensitivity to the moral aspects of
practice Appreciation of vulnerability of patients Embracing of
values expressed in codes of ethics Acceptance of accountability
and moral responsibility
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The moral self is a self always haunted by the suspicion that
it is not moral enough. (Bauman, Postmodern Ethics, p. 80)
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Moral residue George Webster & Franois Baylis Crescendo
Effect Elizabeth Epstein & Ann Hamric
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Journal of Clinical Ethics
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The starkest of alternativeslife and death of children are
focused in sharp relief in the PICU. 1 1.DeMaso, D. & Meyer, E.
(1996). A psychiatric consultants survival guide to the pediatric
intensive care unit. J AM Acad Child Adolesc Psychiatry, 35, 1411-
13. 2.Austin, W., Kelecevic, J., Goble, E. & Mekechuk, J.
(2009). An overview of moral distress and the PICU Team, Nursing
Ethics, 16(1), 57-68. PICUs are high-tech, high-pressure
environments in which physicians (intensivists) co-ordinate a
multidisciplinary team 2 PICU teams include: physicians, nurses,
respiratory therapists, social workers, dieticians, pharmacists,
physical therapists, occupational therapists, psychologists clergy.
2
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High Tech Environment Multidisciplinary Teams End-of-Life
Decision-Making
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Their story, yours, mine - its what we all carry with us on
this trip we take, and we owe it to each other to respect our
stories and learn from them. - William Carlos Williams
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Setting: 6 Canadian PICUs Participants: nurses, intensivists,
dieticians, social workers, respiratory therapists, residents Story
Gathering interviews, focus groups Analysis: extraction of stories
(63) creation of typology Dissemination: Play: Just Keep Breathing;
Website; Presentations & Publications Further research
Secondary analysis re: org influences Dissemination grant
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Part II
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Communication Breakdown Hierarchy & Power differences our
voice not heard (a team?) Multidisciplinary conflicts Conflicts
with families dissimilar goals of therapy diverse views on
disability Patient suffering
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Clinical situations: Unnecessary Treatment Prolonged dying
aggressive treatment Inadequate inform consent Incompetence of
colleagues Being in the middle Internal Factors Perceive powerless
Lack of Knowledge Increased moral sensitivity Lack of FULL
understanding of a situation Amric et al, The Pharos, 2006
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Institution culture/ constrains Lack of time Understaffing Lack
of admin support Polices and priorities and conflict with care
needs Pressure to reduce cost compromising care Reimbursement
constrains Co-worker issues/ different professional perspectives
Amric, A et al, The Faros, 2006
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Debriefing formal and informal Ethics consultation Ethics
training develop tools for sense-making and coping Rounds learning
from cases Interdisciplinary understanding and support Inclusive
decision-making (including family) Time away from unit/situation
Self-care exercise, spirituality, humour, journaling, Sharing with
a colleague; spouse
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Time away from unit/situation Time away from unit/situation
Self-care: Self-care: fitness strategies fitness strategies
spiritual strategies (e.g., rituals) spiritual strategies (e.g.,
rituals) journaling journaling humour humour
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This is not a place where I have the freedom to work
ethically.