A Team-Based Early Action Protocol to Address Ethical Concerns in the Intensive Care Unit

Abstract

Background Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety. Objective To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families. Methods In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables. Results The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change. Conclusions When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced.

Giving nurses a voice during ethical conflict in the Intensive Care Unit

“…12 An important target for research and practice is the inclusion of nurse leaders in proactive ethics rounds with the interprofessional team. 12,36,43,44 Nurses in our study frequently described not feeling heard by their physician colleagues, and some nurses described how they coped by accepting their lack of control in situations of ethical conflict. Indeed, a negative relationship between moral distress frequency and psychological empowerment was found in another study.…”

“…12 An important target for research and practice is the inclusion of nurse leaders in proactive ethics rounds with the interprofessional team. 12,36,43,44…”

“…15 –17 Improving nurse–physician collaboration is a vital area for intervention development to mitigate moral distress in critical care nursing practice. 32,36,44…”

“…poor work environment, hierarchy, inadequate teamwork, inequitable resource allocation) that contribute to ethical conflict and moral distress, 16,17,[32][33][34] fewer have identified the specific resources nurses need organizations to provide to reduce and resolve moral distress in their practice. 4,35,36 Our study identifies key resources including opportunities for interprofessional collaboration on ethical issues, reflective ethical learning, greater engagement in the process of ethical consultations, and integration of palliative and hospice care in the ICU.…”

“…[15][16][17] Improving nurse-physician collaboration is a vital area for intervention development to mitigate moral distress in critical care nursing practice. 32,36,44 Nurses in this study described the value of discussing their ethical perspectives and experiences with providers and being engaged in ethics consultations. Healthcare teams routinely support families, making challenging decisions about life-sustaining treatments in intensive care.…”