Wednesday, September 16, 2009

Moral Distress in the ICU

"Doctor, the patient in room 8 is ready to go to heaven, but no one really seems to understand that but the nurses. Could you please talk to the family?" When I would come on service in the ICU it was not uncommon for the nurses to feel a mixture of frustration, sadness and at times moral outrage at the prolonged care of a terminal patient. The cost of the care really wasn't their issue. The nurse had spent hours at the bedside doing total body care; consoled the distressed family; listened warily to the various specialists who wanted to push on with a treatment like dialysis in a 90 year old patient; tried to titrate pain medications for comfort without oversedation; and extensively documented all information in the patient's medical record.

With a social worker, we developed a methodology of family conferences that basically operates like a mini-ethics committee. The goal is to give information, listen, validate concerns, gain trust, explain options with benefits and burdens, then try to match this with the patient's wishes if known. We had done this many many times, so I would joke with the nurses typical of the dark humor in stress medicine, "Well, let me put on my black cape and let's make rounds before we meet up with the family."

R.N. Theresa Brown's essay in the New York Times points out the devastating effect of prolonged futile care on nurses in the ICU. Also, I think there is likely undocumented similar distress among doctors and other care gives like social workers. Many critical care doctors retire early, move laterally into sleep medicine, or move into being a concierge doctor. The burnout surfaces in a number of ways. I know of one doctor who divorced his first wife to marry an ICU nurse, divorced her later to marry a second ICU nurse and then left ICU work for a limited low stress practice.

The social worker in our ICU would hold frequent debriefings with the staff and try to be helpful for the mental anguish that occurs particularly in the situation of medical futility where a dysfunctional family is involved with poor decision making skills at times magnified by alcohol or drug abuse. These are the really tough situations.

There is finally more attention, training, and research being done on how to deal with the issue of medical futility, but those at the bedside will have to endure the realities, stresses, and moral suffering. Hopefully, medical and nursing training and communication will continue to improve in this area - and lessen moral distress.

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