Ethics in the Intensive Care Unit PDF 2015

http://dx.doi.org/10.4046/trd.2015.78.3.175 REVIEW ISSN: 1738-3536(Print)/2005-6184(Online) Tuberc Respir Dis 2015;78:175-179 Ethics in the Intensive Care Unit Jae Young Moon, M.D., Ph.D. and Ju-Ock Kim, M.D., Ph.D. Department of Internal Medicine, Chungnam...

http://dx.doi.org/10.4046/trd.2015.78.3.175 REVIEW ISSN: 1738-3536(Print)/2005-6184(Online) Tuberc Respir Dis 2015;78:175-179 Ethics in the Intensive Care Unit Jae Young Moon, M.D., Ph.D. and Ju-Ock Kim, M.D., Ph.D. Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea The intensive care unit (ICU) is the most common place to die. Also, ethical conflicts among stakeholders occur frequently in the ICU. Thus, ICU clinicians should be competent in all aspects for ethical decision-making. Major sources of conflicts are behavioral issues, such as verbal abuse or poor communication between physicians and nurses, and end- of-life care issues including a lack of respect for the patient’s autonomy. The ethical conflicts are significantly associated with the job strain and burn-out syndrome of healthcare workers, and consequently, may threaten the quality of care. To improve the quality of care, handling ethical conflicts properly is emerging as a vital and more comprehensive area. The ICU physicians themselves need to be more sensitive to behavioral conflicts and enable shared decision making in end-of-life care. At the same time, the institutions and administrators should develop their processes to find and resolve common ethical problems in their ICUs. Keywords: Ethics; Behavior; Terminal Care; Intensive Care Units Introduction Impact of Ethical Conflicts in the ICU Physicians often experience ethical dilemmas in the clini- Today’s health care environment is increasingly complex. cal field. The intensive care unit (ICU) is the most common The complexity of technology-driven modern health care, val- place of ethical conflicts, and many respiratory physicians face ue heterogeneity, individual rights, and the number of choices with these conflicts frequently. Recently, the intensive care according to individual values are less conductive to good dedicated system was implemented, and the critical care en- decision making1. Despite considerable technologic break- vironment is rapidly changing in Korea. In this paper, we will throughs in the provision of intensive care medicine, mortality describe the impact of ethical dilemmas on the quality of care in the ICU remains high2 and ethical conflicts among stake- and the role of the ICU physicians with respect to such dilem- holders occur frequently in contemporary health care settings. mas. These may have negative impacts on healthcare workers, patients, and their families, and lower the quality of intensive care. In a previous study, over 70% of ICU workers reported per- Address for correspondence: Ju-Ock Kim, M.D., Ph.D. ceived conflicts, which were often considered severe and were Department of Internal Medicine, Chungnam National University School significantly associated with job strain3. Nurses perceived of Medicine, 266 Munhwa-ro, Jung-gu, Daejeon 301-747, Korea distressing situations more frequently than physicians did; Phone: 82-42-280-7158, Fax: 82-42-257-5753 E-mail: [email protected] additionally, 45% of the registered nurses surveyed reported Received: Feb. 2, 2015 having left or having considered leaving a position because Revised: Feb. 17, 2015 of moral distress4. The ICU is one of the places in the hospital Accepted: Feb. 23, 2015 where family members suffer. More than two-thirds of family members visiting ICU patients have symptoms of anxiety or cc It is identical to the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/). depression. In a French study, it was found that 75.5% of fam- ily members and 82.7% of spouses had symptoms of anxiety Copyright © 2015 or depression in a multicenter study including 78 ICUs and The Korean Academy of Tuberculosis and Respiratory Diseases. 544 family members5. All rights reserved. 175  JY Moon et al. Major Sources of Ethical Conflicts in the ICU in ICUs were behavior-related conflicts and conflicts associated with end-of-life (EOL) care. The most common conflict-causing The incidence of ethical conflicts is higher in the ICU behaviors were personal animosity, mistrust, and communi- compared with the general wards. In a 3-year period during cation gaps. During EOL care, the main sources of perceived which a large urban teaching hospital had a total of 181,558 conflict were a lack of psychological support, absence of staff admissions, the hospital ethics committee staffed 0.16% of meetings, and problems with the decision-making process. consultations. The services with the highest incidence of eth- In particular, verbal abuse was one of the conflict-causing ics committee consultations were the trauma ICU (0.88%) behaviors, and nurse-physician disruptive behavior was found and medical ICU (0.56%)6. In another 1-year study, 4,968 pa- to have a negative impact on patient safety10. As Sofield and tients were admitted to the adult ICUs at Columbia University Salmond’s study reported11, 51% of respondents reported Medical Center and 168 ethical consultations (3.3%) were re- patient errors occurred as a result of such behavior. The most quested7. Although there are few reports on domestic data, ac- common forms of verbal abuse and/or disruptive behavior cording to a single center study by Park et al.8, the incidences was condescending language. Other common types of disrup- of perceived conflicts that registered nurses reported during tive behavior included disrespect and a failure to return phone two different study periods were 2.1% and 0.5%, respectively. calls12-15. In many studies, between 17% and 41.9% of health- Swetz et al.’s study9 showed the common diagnoses of cases care providers reported a specific adverse event that occurred referred to consultation at the Mayo Clinic in Rochester, Min- as a result of disruptive behavior16,17. As a result, eleven recom- nesota, during a 10-year period, including malignancy (18%) mendations have been made by The Joint Commission to help and neurologic disease (18%), followed by cardiovascular organizations implement the group’s standards (Table 1)18. disease (17%), multi-organ failure (11%), pulmonary disease (9%), and others. According to Romano et al.’s study7, the most common diagnosis was cardiovascular disease, followed by Burnout Syndrome and Moral Distress neurologic disease, pulmonary disease, renal disease, gas- of Health Care Professionals trointestinal disease, malignancy, multi-organ system failure, psychiatric disease, developmental or genetic disease, and ICU caregivers work in a stressful environment, which can miscellaneous. lead to burnout syndrome19. In addition, the ethical environ- The 1-day cross-sectional questionnaire survey from 397 ment of their unit and ethical conflicts cause moral distress, ICUs in 29 countries showed that conflicts were perceived by which is believed to be associated with burnout. 5,268 respondents (71.6%) and that nurse-physician conflicts It is well known that burnout can affect up to 45% of ICU were the most common (32.6%)3. The major sources of conflicts nurses and physicians20,21. Burnout is a psychological syn- Table 1. The Joint Commission Recommendations for managing disruptive behavior No. Joint Commission Recommendations 1 Educate all team members on appropriate behavior defined by the organizations code of conduct 2 Enforce the code of conduct consistently and equitably among all staff 3 Develop and implement policies that address - “Zero tolerance” for disruptive behavior - Complementary policies for physicians and non-physicians - Non-retaliation clauses - Response to patients and/or families who experience or witness disruptive behavior - Disciplinary actions 4 Develop a process for addressing disruptive behavior with input from medicine, nursing, administration, and other employees 5 Provide training in conflict resolution 6 Assess staff perceptions of disruptive behavior and threat to patient safety 7 Develop a reporting/surveillance system for identifying disruptive behavior 8 Support surveillance with tiered strategies - move toward discipline if pattern persists 9 Conduct interventions with a commitment to well-being of all staff 10 Encourage interprofessional dialogues 11 Document all attempts to address behavior Source: The Joint Commission18. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm. 176 Tuberc Respir Dis 2015;78:175-179 www.e-trd.org Ethical dilemmas in the intensive care unit drome that occurs in response to chronic emotional and inter- as being an ethical or moral problem. An example is do not personal stressors at work. It can lead to emotional instability, resuscitate (DNR) orders on chronically ill patients. The prob- commitment difficulties, a feeling of failure, and an urge to lems arising from knowledge deficits could decrease consider- leave one’s job. Consequences to caregivers’ health include ably if professionals receive training or education in recogniz- insomnia, irritability, and depressive symptoms, which in turn ing the associated moral problems and how to be competent can impact the quality of the care they provide20,22. Burnout in in moral standards of care29. This is the reason why education physicians tends to manifest as the provider caring less for his in ethics is important. or her patients, and the number of medical errors increases22,23. Doctors’ and patients’ values sometimes differ, and even The Maslach Burnout Inventory, which measured the burn- though medical decision making is complex, it should be ap- out of the nurses who work in Korean university hospitals, dem- proached using the principles of bioethics. Such ethical deci- onstrated significant emotional exhaustion and high-burnout sion making training in the clinic would make patients’ best conditions in that professional environment and profession24,25. interests and health professionals’ values consistent with the In Canada, it was found that internal medicine residents fundamental values of our society. value the opportunity to learn from dying patients, but often lack supervision and then experience emotional distress26. The majority of respondents agreed the learning experience gained Ethical Issues of EOL Care in the ICU from providing EOL care was meaningful, although 48.1% felt guilty and 40.6% felt failure at least some point after a patient’s During EOL care, the main cause of ethical conflict was death. A domestic single center study reported that 69.1% of found to be the inappropriateness of care, including a lack residents encountered serious ethical dilemmas at least once of psychological support and problems with the decision- a year, but the majority of these residents claimed to have making process. In Korea, most terminal cancer patients die in resolved those dilemmas either alone or through discussions medical institutions. However, the quality of EOL care in Kore- with colleagues without an attending physician’s advice27. an ICUs does not ensure the terminally ill patient’s autonomy The high rate of physician suicide is also well known; the and dignity at the end of the patient’s life. suicide rate among male doctors is 40% higher than among One of the most important EOL issues is how health men in general, whereas the rate among female doctors is care professionals communicate the patients’ prognoses to 130% higher than among women in general28. Health care them30,31. Accurate prognostic information helps patients and professionals are frequently exposed to emotional stress and physicians make sound medical decisions and care choic- exhaustion. es31,32. Yun et al.’s study31 found that patients who learned their prognoses from their physicians had better outcomes, such as lower rates of emotional distress and a higher health-related Type of Ethical Problems and Education quality of life (QOL), but a substantial proportion of patients in Ethics did not receive such information from their physicians. De- spite the fact that most patients are resistant to chemotherapy When we examine the behavior of the health professionals regardless of cancer type near the EOL, chemotherapy was still involved, it can be seen that different types of moral behavior frequently administered in Korea33. However, a multicenter can give rise to these problem. Types of ethical problems are prospective cohort study of patients with cancer entering the presented in Table 229. terminal stage of their disease shows that the patients’ aware- A lack of knowledge or education in health ethics is a com- ness of terminal illness, use of palliative care, and admission to mon cause of ethical dilemmas occurring in ICU. This mani- an ICU do not influence the survival of terminally ill patients34. fests when the health professional does not see a situation Surrogate decision-making was frequently observed among Korean cancer patients, especially when the patient’s death was imminent, and for decisions related to EOL care. The pro- Table 2. Various types of moral behavior of health professionals portion of patient self-determination for DNR directives was No. Type extremely rare near the EOL period, far from an ethical ideal35. 1 Problems caused by knowledge deficits Annually, thousands of terminal cancer patients still die under 2 Problems caused by authority cardio-pulmonary resuscitation in Korean ICUs. Among nurs- es and physicians who work in adults ICUs in Europe, percep- 3 Problems arising from ‘groupie’ moral standards tions of inappropriate care have been frequently reported. The 4 Problems caused by moral insensitivity main reported reason for perceived inappropriateness of care 5 Problems caused by amoral behavior was a mismatch between the level of care and the expected 6 Problems caused by differences of opinion patient outcome, usually in the direction of perceived excess 7 Problems caused by oppositional views intensity of care36. www.e-trd.org http://dx.doi.org/10.4046/trd.2015.78.3.175 177  JY Moon et al. Despite all the literature, there is little discussion about the physicians can identify or resolve ethical dilemmas41. QOL of terminal cancer patients in their end-stages of life or Good clinical decision-making is only possible when the the optimal triage of admission to an ICU. According to US medical decision-making and ethical decision-making are Medicare database, from 1993 to 2002, an increasing propor- correctly balanced. Knowledge about common ethical dilem- tion of patients who had been diagnosed with advanced lung mas and training in ethical decision-making is essential. At cancer received ICU care near the end of their lives. Two- the same time, the ICU leaders and hospital directors should thirds of patients died either during or within 1 month of hos- prepare protocols to find and resolve the common ethical pitalization37. Hwang et al.’s study38 showed that ICU mortality problems in their hospital. and in-hospital mortality rates of patients with lung cancer ad- mitted to the medical ICU were 53.6 and 61.8%, respectively; very poor values. Conflicts of Interest No potential conflict of interest relevant to this article was Shared Decision Making reported. The ICU is not the adequate place for the care of terminally ill patients because it is not designed for EOL care. If the dis- References ease state of the patient is not curable, how can we determine the best treatment goals for the patient? 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