UCLAHealthSystemEthicsNewGradProgramKatherine Brown‐Saltzman, MA, RNCo‐directorUCLA Health System Ethics CenterAssistant Clinical ProfessorUCLA School of Nursing 

MoralDistressinNewGrads• New material Kelly, B. Associate Professor, Preserving moral integrity: a follow‐up study with new graduate nurses. Journal of advanced nursing v.28 (5), 1998, 1134‐

EthicsCenterTeam

• Neil Wenger, MD, MPH Director

• Katherine Brown‐Saltzman, MA, RNCo‐director

• James Hynds, LL.B., PhD Senior Clinical Ethicist

• Joseph Raho, PhDClinical Ethicist

• Janine‐Mariz Burog, MSHA• Administrator

Clinical Ethics FellowsValerye Milleson, PhDSenior FellowJohn Frye, PhDFellow

ContacttheEthicsCenter

Pager: “ETHIC”/38442Webpage:www.uclahealth.org/ethics

Email:ethicscenter@mednet.ucla.edu

Phone:310 794‐6219

HistoryoftheEthicsCenter

The Ethics Center began in 2002 Board of Directors identified ethical issues as an area for improvement in providing cutting edge care at UCLA.

2005 Appointment of Director and Co-director

2006 Hiring of Clinical Ethicist

2011 Ethics Fellowship

SomeInstitutionalBenefitsoftheEthicsCenter• Availability: 24/7 emergent on call 

Page: Ethics/#38442• Facilitate relationship‐based care in the midst of conflict

• Provide continuity of care• Promote discussion of values and ethical awareness

• Address moral distress = reduction of burnout, staff turnover, and a leaving of the profession

• Encourage awareness of resource allocation

TheCenter’sActivities• Clinical Consultation• Professional Consultation• Education• Ethics Committees (RR, SMH, NPH)• Policy Development and Review• Research/Publication• Innovative Programs• Staff Support• Community Resource

Education• Bi‐monthly Noon Ethics Lecture Series• Ethics Fellowship• Nursing Ethics Associate Program• Ethics Committee Programs• Monthly Journal Club• Community/National/International Presentations• Lectures/Panels

• Departments (Nursing, Spiritual Care, Medicine, Geriatrics, etc.)• Schools (Medicine, Nursing, Law, Public Health)• Community• Pediatric Palliative Care Comfort Panels• Community/National/International Presentations

EthicsFellowship• The goal of this two year fellowship is to provide extensive clinical consultation experience, with opportunities in the second year for research, teaching, and mentoring of the junior fellow.

• The Fellowship is for individuals who hold an advanced degree in health care ethics.

InnovativePrograms• Collaborating with Department of Nursing 

• Bi‐annual Circle of Caring: A Renewal Retreat for Healthcare• This program teaches self‐care as an ethical practice.

• Ethics Institute Fellowship (Prior)• The Ethics Institute gives nurses the tools to deal with the ethical questions they face every day and helps them become influential participants in the larger discussion of ethics taking place throughout the healthcare profession.

• Nine nurse fellows – NICU, MICU, PICU, Medicine, CTU, MOU Neuro ICU

• Nursing Ethics Associate Program Summer 2017

InnovativePrograms

• Moral Distress Writing Retreat

• End‐of‐Life Education Program for Respiratory TherapistsBrown‐Saltzman K, Upadhya D, Larner L, Wenger NS. An intervention to improve respiratory therapists' comfort with end‐of‐life care. Respir Care. 2010 Jul;55(7):858‐65.

CommunityResource• Ethics of Caring Conference

• Collaboration with 16 institutions• Over 300 attend• Grew to a National Nursing Ethics Conference NNEC (2011, 2013, 2015,2017)

• Now an annual National Nursing Ethics ConferenceNNEC March 8‐9, 2018 here on campus, at the UCLA Luskin Conference Center

EthicsofCaringConferenceSurveyofParticipantsThose who attended 2 or more of the conferences

were significantly

More confident in ability to identify ethical issues

More comfortable approaching colleagues to discuss ethical issues

More satisfied with personal skill to address ethical issues

More aware of available resources to address ethical issues

ClinicalConsultationA snapshot of consultations over the past year:

• UCLA  n = >275 

• National  90% of consult services surveyed performed fewer than 25 consults per year (n =519 hospitals)

WhatisClinicalConsultation?Having All the Answers. Not Quite!

Whataretheissues?

• Conflicts about goals of treatment• Conflict between family members • Un‐represented patients (without surrogates homeless, elders etc.)

• Patient suffering/non‐beneficial treatment• Confidentiality – HIV Status, Misattributed paternity, Privacy

• Informed Consent• Innovative treatment • Pediatrics – wishes of parents vs. best interest of patient• Evaluating complex capacity for decision making • Moral distress• Resource utilization

SourcesofConsults• SW’s, RN’s, MD’s, Families, Patients, Case Managers, Chaplains, Risk Management 

• Units with requesting consults routinely:• MICU, MOU, NICU, CCU, Neuro ICU, PICU, Medicine, CTU, Surgery, Transplant 

• SM – ICU & Geriatrics

What’stheproblem?

• Generally, teams have not communicated well about ethical issues 1‐5

Conflict  Not knowing  Disagreement  It takes time Hierarchical structures  Fears  Perspectives vary Hope of resolution Avoiding harm

TheConsequencesofConflict

• Persistent moral discomfort / stress / distress.6,7

• Crescendo effect of moral distress; moral residue.8

• Can lead to medical errors, harmful decisions and  unnecessary patient suffering.9‐11

• Affects all HCPs, especially nurses (time / space).6,7

• Influences professional relationships, teamwork.12‐16

• Contributes to disengagement, professional burnout.2,3,6,7

• Accounts for substandard health care.9‐11,17

EthicalPrinciples

• Beneficence• Nonmaleficence• Autonomy• Best Interest• Justice – Distribution of Limited Resources• Fidelity

Autonomy

• Right to self‐determine about how one’s body will be treated

• Capacity

ComplexityofAutonomy

• Patients with C4 C3 spinal cord trauma90% asked to dc the respirator post‐accident

Autonomous Decision?

• Following rehab – 95% of the pts were glad to be alive and no longer wished to have their respirators turned off

Patterson DR, Miller‐Perrin C, McCormick TR, Hudson LD. When life support is questioned early in the care of patients with cervical‐level quadriplegia. N Engl J Med.1993 Feb 18;328(7):506‐9. 

Futility

“A treatment is medically futile when the magnitude of the 

benefit, however it contributes to the patient’s treatment 

goals is disproportionately small in relation to the 

magnitude of the risks of violating the patient’s integrity 

worsening the patient’s condition or when compared to 

the magnitude of the effort needed to achieve the benefit.” 

RMEC National Center for Ethics 1993 

PrognosticatingDifferencesbetweennursesandphysicians

n = 603 pediatric ICU patients 36 deaths 5.61%

Mean mortality predictions  attendings (6.09%)  fellows (7.87%) residents (10.00% nurses (16.29%)

Marcin JP. et al. Prognostication and certainty in the pediatric intensive care unit. Pediatrics. 1999 Oct;104(4 Pt 1):868‐73.

PrognosticationStudyforPatientswithAdvancedCancer1,018/1,783MulticenterGwilliamB,KeeleyV,ToddCetal(2011)Developmentofprognosisinpalliativecarestudypredictormodelstoimproveprognosticationinadvancedcancer:prospectivecohortstudy.BMJ343:4920–4934.

Clinician

• Physician

• Nurse

• Multi Professional Estimate 

Error Rate

• 43.7 %

• 44.8 %

• 42.5 %

HarmfulTreatment

Harming a patient violatesthe principles of:

Nonmaleficence Beneficence Best Interest Fidelity Justice 

AnInklingoftheDifficulties

Nurses see the suffering of many Physicians see the possibility of cure

۞

Benefits vs. Burdens Best InterestQuality of Life

۞Who Decides?

FutilityPredictionsandSurrogateResponse

64 % doubted the accuracy of the physician prognosis 32% elected to continue life support with a < 1% survival estimate  18% elected to continue treatment when the physician believed there was no chance of survival

N = 50

Zier LS. et al. Surrogate decision makers' responses to physicians' predictions of medical futility. Chest. 2009 Jul;136(1):110‐7. Epub 2009 Mar 24.

ViewoftheWorldbyPatients

Despite the fact that 71 % participants had metastatic or recurrent disease. The level of hope was relatively high, even in those patients who knew that their disease was in an advanced stage.  

Hope was positively related to coping in patients with cancer, regardless of gender, age, marital status, education, or site of malignancy.

ViewoftheWorld:PatientsandFamilies

Whydopatientsortheirfamilieswantnon‐beneficialtreatments?

Confusion – i.e. why would I be offered treatment that is non‐beneficial? Do not believe the prognostication is correct Hope that has been inaccurately sustainedWaiting for a miracle or other faith beliefs Inability to make a decision – do not want to carry the responsibility

PolicytoAddressNon‐beneficialTreatment• Policy 1319 

• Withdrawing or Withholding Medically Inappropriate Life Sustaining Treatment

• Policy 1319.1  • No CPR Orders

EXPEDITEDUNILATERALNOCPRORDER:IMMINENTLYDYINGPATIENTS

A. Where the attending physician judges that CPR is not a medically appropriate intervention for the patient because it would serve only to prolong the patient’s irreversible dying process and is reasonably certain that the patient’s death is imminent, and there is a conflict between the patient/Legal Decision Maker and the physician about providing CPR, he may write a No CPR order without the consent of the patient or their Legal Decision Maker and without exhausting the conflict resolution process delineated in Section I. D (above), if, but only if, the procedures in this section are followed. 

Definition:MoralDistress

• Occurs“whenoneknowswhattodobutinstitutionalconstraintsmakeitnearlyimpossibletopursuerightcourseofaction”(Jameton,1984)

1984

• “Experienceofbeingseriouslycompromisedasamoralagent;relationalexperienceshapedbyworkplaceenvironment”(Varcoe,Pauley,Webster,&Storch,2012)

2012

ConsequencesofUnresolvedEthicalDilemmas/Conflicts

• Persistent moral discomfort / stress / distress • Crescendo effect of moral distress; moral residue• Affects all HCPs, especially nurses (time / space)• Influences professional relationships, teamwork• Contributes to disengagement, professional burnout• Can lead to medical errors, harmful decisions and  unnecessary patient suffering

• Accounts for substandard health care• Epstein & Hamric, 2009; Leonard, Graham, & Bonacum, D. 2004

“TheCrescendoEffect” Epstein,Hamric

Moral Distress

Moral residue

TimeParents agree to withdraw

Deflation of moral distress

Nursing staff believes that further aggressive treatment is futile

Problem: Ethical Conflicts

Critical Incident Study(70 nurses – risk factors, early indicators)

Ethics Advocacy Tool(28 ICU/oncology nurses; 2 sites)

Focused Ethnography (30 oncology nurses; 12 key informants)

Ethics Online Survey(114 physicians)

Critical Incident Study (100 CNS, nurse leaders)

Exploratory Study on collaboration with physicians and nurses

Collaborative Proactive Ethics Protocol(6 ICU’s/3 sites)

Concerns about: Safety, Quality, Moral Distress

Protocol validation: Case vignette with 15 clinical ethicists

Protocol validation:Case consultation document reviewN=25

Nurse‐Physician Focus Groups(6 nurses and 6 physicians)

Findings:RiskFactorsforEthicalConflictsNurses’Perspectives18

Individual Risk FactorsPatient vulnerability  (87%)Near end of life  (73%)Patient suffering  (71%)Failed treatments  (64%)

Family Risk FactorsDisagreement with plan (42.9%)Adamancy  (30%)Uncertainty  (27.1%)

HCP Risk FactorsLack of team cohesion  (34.3%)Unethical behavior  (28.6%)Conflict among team  (22.9%)False hope offered  (21.4%)

System Risk FactorsLack of limit setting  (37.1%)Unclear policies  (25.7%)Limited resources  (14.3%)

Multi‐level RisksPoor communicationLack of knowledgeDifferent cultures

Drug dependence

Patients (N=51)Complex medical needsLack of capacityMental illnessVery young or very oldNo family supportLow SES / homelessnessLack of educationDrug dependence

Families (N=17)Low trust in providersNegative past experiencesUnrealistic expectationsLack of educationPoor decision making skillsMultiple family members

Providers (N=14)Overly‐aggressiveEmotionally involvedOver‐workedStressed, burned out

Inadequate processes (N=53)Poor communication (N=34)Lack of cohesive plan of care (N=19)

System CircumstancesN=13 (6.3%)

Personal CircumstancesN=82 (39.8%)

Interactional CircumstancesN=111 (53.9%)

Differences (N=58)Differing worldviews (N=25)Moral disagreements (N=33)

Inadequate resources (N=7)

Inadequate institutional support (N=4)

Unequal distribution of resources (N= 2)

RiskFactorsforEthicalConflicts:Physicians’Perspectives19

N = number of times risk factor was identified 

Increased Risk for Ethical Conflicts

N=206

Findings:Nurses’Regrets

40%reportedregrets(n=28)

• Unnecessarypatientsuffering(n=10)• Notdoingenough(n=9)• Lackofpoliciesonmedicalfutility(n=5)• Beingdishonest(n=3)• Nurse’sposition(n=1)• “Myhandsweretied”• “Beinginthemiddleofsituationscreatedbyothers”• “ThiscasehashauntedmeforyearsasIfeelIcouldhavebeenabetteradvocateforher.”

Pavlish, C, Brown-Saltzman, K, Hersh, M, et al. Early indicators and risk factors for ethical issues in clinical practice. Journal of Nursing Scholarship 2011 43(1), 13-21.

Nurses’Regrets20

“This case has haunted me for years as I feel I could have been a better advocate for her.”

Physicians’QuotesonMoralStress19

• “The desire to meet others’ needs makes you think about whether your own moral code is absolute or whether you can act according to someone else’s and still sleep at night.”

• “The ability to take oneself out of the situation when forced to do something such as a procedure.”

• “Not really knowing in one’s heart what the right answer is.”

ProfessionalGoals•Preventsuffering,injury•Behonestandinformpatient•Contributetopatient’simprovement/statedgoals

Moral Appraisal of Ethically‐Difficult Patient Situation

ChallengesforNursesWorkinginEthically‐DifficultSituations

•Beingtheeyesandarmsofsuffering(oftenwithoutavoice)•Experiencingtheprecariousnessofcompetingobligations•Navigatingintricaciesofhopeandhonesty•Managingurgencycausedbywaiting•Strainingtofindtime•Weighingrisksofspeakingupinhierarchalstructures

RiskAppraisal(Mediatorsofaction)

•Trustinteamrelationships,management•Strengthofrelationshipwithpatient•Self‐confidence(education/experience)•Opportunityforcommunication•Influenceoftime:emotionsbuild;limitedtime

NurseActionsinEthicalConflicts•Speakingup:Directlyaddressingconcerns•Speakingaround:Creatingotheravenues•Speakingsideways:“Murmuring”tooneanother•Stayingsilent:Sufferingquietly•Lookingaway:Focusingontasks

Moral MoralSensitivityJudgment

Moral MoralMotivationCharacter

PossibleConsequencesforNurses•Moralcomfort,stress,distress•Brokentrust,relationships,confidence•Learning,self‐confidence,satisfactionDependsonactiontakenandpatient,family,team,managementresponsestonurseaction.Responsesaffectallwhowitnessandinfluencefutureactionsformany.

Nurses’ Moral Kaleidoscope 

SituationalOutcomesfor:

•Patientandfamily•Healthcareteam•Healthcareorganization

ContextualandDynamicModelofMoralAction21

James Rest, 1994

Findings:RiskyEnvironmentsNursesperceivedconsiderableriskswhenspeakingupunderconditionsof:

•Moraluncertainty• Significantpowerdifferentials• Inadequatemanagementsupport• Fracturedcareplanning• Relationalconflict

Pavlish, C, Brown-Saltzman, K, Hersh, M, et al. Early indicators and risk factors for ethical issues in clinical practice. Journal of Nursing Scholarship 2011 43(1), 13-21.

PilotStudyofanEthicsScreeningandEarlyActionTool22

• 28criticalcareandoncologynurses– UCLAandMayoClinic

• 4hourethicsworkshop• 3monthsutilization of screening tool

‐ Completebriefquestionnaireincludingethicssituation(ptdx,situation),timeneededtocompletetool,anditsusefulnessforthatparticularsituation

• PostTooluseafter3months:‐ Completeasurvey‐ Attendafocusgroup

EthicsScreeningandEarlyInterventionTool22

1. Identifyriskfactorsandearlyindicators

2. Assesslikelihoodofconflictoccurring

3. Identifyappropriateactions

4. Appraiseriskofnegativeconsequencesoccurring

TopRiskFactors&Indicators

• Riskfactorsandearlyindicatorsmostfrequentlycheckedineachcategory.

TopThreeIndicatorsofHighRiskforEthicalConflicts22

Top 3 indicators in both settings pertained to:

Patient suffering Provider distress Family’s unrealisticexpectations

Three Aspects Equals Shared Suffering

*Image - Mica Endsley, Ph.D., President, SA Technologies

SilenceDespiteanEvidence‐BasedScreeningTool5

• Despitenurses’commentsabouttheempoweringbenefitsofthescreeningtool,severalnursesstillremainedsilentabouttheirconcerns.

PerceivedRiskinFollowingUp5

0

0.5

1

1.5

2

2.5

3

3.5

4

Physicians Ethics Consult Patient/Family

Site 1

Site 2

Other options: colleagues, nurse management, social work, chaplain, palliative care, other.

1. Discuss with physician: “Youbringupyourconcernstothedoctorandconcernsareshooedaway,likewhatyouhavetosayisnotnecessarilyimportantorIshouldn’tbequestioningadoctor.”

2. Explore with patient/family: “OnethingIseeasbeingthemostriskyishowmuchshouldItell[thefamily],howshouldwetalkabout[whatmighthappen],oraskwhatareyourgoalshere?Itfeelsrisky.

3. Initiate ethics consult: “Ethics is kind of sometimes taboo because… you don’t want

anyone to feel like you’re a whistle blower or you always have a problem with something.”

PerceivedRiskinFollowingUp

ScreeningTool:Follow‐upFocusGroups

“SoIknewthattherewassomethinggoingonandthisguymightcodeandwe’redoingallthesethingstohimandIalreadyknewthatthiswasgoingtoendupbeingsomesortofethicsthing,butthetoolconfirmedit.Ithinkinalessobviouscasewherethesonjustwasn’tlettingusdoanything[forpain],theproblemswerenotquiteasclearandsocheckingoff‘Disagreements’Yes.‘Patientsuffering.’OhmyGod,yes.‘Moraldistress.’Ofcourse.‘Unrealistic’Imeanitwaslikeyes,yes,yes.Soit[tool]reallyputswordstothethingsthatareambiguousorthethingsthatyoucan’thoneinonbecauseyou’resobusydeliveringcare,especiallytocriticallyillpatients.”

PilotStudyConclusions

• Nursesjudgedthetooltobe: Feasible Easytouse Effective

• SuggestedImprovements: Standardizeuseofthetoolforallpatients.Makethetoolmultidisciplinaryandcollaborative. Providemoreobjectivecriteriafordeterminingrisklevel. Givemorespecificguidelinesforfollowupactions.

RevisionstotheTool

• SuggestionsfromPilotStudy

• ExpertReviewoftherevisedtool• 15ClinicalEthicists• DocumentReviewofEthicsConsultations

• IncorporatedOtherVoices• PhysicianSurvey19

• NurseLeadersSurvey23

CurrentProjectGOAL– tostudyeffectivenessofaninterdisciplinary,ethicsearlyactionintervention

•Multi‐sitestudyin6ICUsinthreesettings:

• UCLA,MayoClinicandMassachusettsGeneralHospital

• EnrollingICUnurses,physicians,PAs,andNPs

• OutcomeMeasures: Primary: number/timingoffamilycareconferences,codediscussions,andethicsconsultations;LOS

Clinicians:moraldistress,ethicalclimate,ethicsself‐efficacy

Families: satisfactionwithcareanddecisionmaking

Funding–ImpactGrantfromAmericanAssociationofCritical‐CareNurses

ImplementingtheProtocol• Incorporated into existing systems of care

• Daily rounds/Interdisciplinary Rounds • Nurses initiate – succinct discussions on rounds

• Assessment:• Every ICU patient• Initial assessment, scoring, and plan within the first 48 hours of ICU admission

• Brief daily reassessment and plan update

• Documentation

SummaryofPreliminaryFindingsClinician Outcomes

• Decrease in clinician moral distress

• Increased perception of individual effectiveness in dealing with ethical issues

• Increase in perception of ethical climate of their work environment

Hypothesis Result

SummaryofPreliminaryFindings

Clinical Outcomes

• Length of ICU stay• Family Conferences (frequency and timing)

• Code Conversations (frequency)

• Ethics Consultations (frequency; small N)

Hypothesis Result

CollaborationasaKeyComponentofMoralCommunities4,24,25

• Patientsasacommoninterest/responsibility

• Ethicsasnormal,everydayconversation

• Openspaceforethicsdialogue

• Opencommunicationwithpatients

• Shareddecisionmakingandcohesivecareplanning

• Mindfulinterdependenceandmutualempowerment

• Leadershipsupportforcollaborativeandproactiveethics

TheHumanSideofEthics

Integrity

“The whole course of human history may depend upon a change of heart in one solitary and even humble individual.”   

M Scott Peck

References1. Azoulay, E., Timsit, JF., Sprung, CL et al., (2009). Prevalence and factors of intensive care unit conflicts: the conflictus study.

American Journal of Respirator Critical Care, 180, 853-860.

2. Fassier, T., & Azoulay, E. (2010). Conflicts and communication gaps in the intensive care unit. Current Opinions in Critical Care, 16, 654-665.

3. Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(Suppl 1), i85-i90.

4. Pavlish, C., Brown-Saltzman, K., Fine, A. et al. (2015). A culture of avoidance: Voices from inside ethically difficult clinicalsituations. Clinical Journal of Oncology Nursing.

5. Pavlish, C., Henriksen Hellyer, J., Brown-Saltzman, K et al., (2013). Barriers to innovation: Nurses’ risk appraisal in using anethics screening and early intervention tool. Advances in Nursing Science, 36, 304-319.

6. Austin, W. (2012). Moral distress and the contemporary plight of health professionals. HEC Forum, 24, 27-38.

7. Pendry, P. (2007). Moral distress: recognizing it to retain nurses. Nursing Economics, 25(4), 217-221.

8. Epstein, E., & Hamric, A. (2009). Moral distress, moral residue, and the crescendo effect. The Journal of Clinical Ethics, 20(4), 330-342.

9. Aiken, L., Clarke, S., Sloane, D., Lake, E., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223-229

10. Balvere, P., Cassells, J., & Buzaianu, E. (2012). Professional nursing burnout and irrational thinking. Journal for Nurses in Staff Development, 28(1), 2-8.

11. Cimiotti J., Aiken, L., Sloane, D., & Wu, E. (2012). Nurse staffing, burnout, and healthcare-associated infections. American Journal of Infection Control, 40, 486-490.

12. Edelstein, L., DeRenzo, E., Waetzig, E., Zelizer, C., & Mokwunye, N. (2009). Communication and conflict management training for clinical bioethics committees. HEC Forum, 21(4), 341-349.

References13. Garon, M. (2012). Speaking up, being heard: Registered nurses’ perceptions of workplace communication. Journal of

Nursing Management, 20, 361-371. 14. Ulrich, C., Hamric, A., & Grady, C. (2010). Moral distress: A growing problem in the health professions? Hastings Center

Report, 40(1), 20-22.

15. Van Soeren, M., & Miles, A. (2003). The role of teams in resolving moral distress in intensive care unit decision-making. Critical Care, 7, 217-218. doi:10.1186/cc2168

16. Rosenstein, A., & O’Daniel, M. (2005). Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. American Journal of Nursing, 105(1), 54-64.

17. Joint Commission. (2009). Leadership in healthcare organizations: A guide to Joint Commission leadership standards. http://www.jointcommission.org/assets/1/18/WP_leadership_standards.pdf

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