J Korean Med Sci.  2015 Apr;30(4):495-501. 10.3346/jkms.2015.30.4.495.

Ethical Issues Recognized by Critical Care Nurses in the Intensive Care Units of a Tertiary Hospital during Two Separate Periods

• Park DW
• Moon JY
• Ku EY
• Kim SJ
• Koo YM
• Kim OJ
• Lee SH
• Jo MW
• Lim CM
• Armstrong
• Koh Y

• KMID: 2164460
• DOI: http://doi.org/10.3346/jkms.2015.30.4.495

Abstract

This research aimed to investigate the changes in ethical issues in everyday clinical practice recognized by critical care nurses during two observation periods. We conducted a retrospective analysis of data obtained by prospective questionnaire surveys of nurses in the intensive care units (ICU) of a tertiary university-affiliated hospital in Seoul, Korea. Data were collected prospectively during two different periods, February 2002-January 2003 (Period 1) and August 2011-July 2012 (Period 2). Significantly fewer cases with ethical issues were reported in Period 2 than in Period 1 (89 cases [2.1%] of 4,291 ICU admissions vs. 51 [0.5%] of 9,302 ICU admissions, respectively; P < 0.001). The highest incidence of cases with identified ethical issues in both Periods occurred in MICU. The major source of ethical issues in Periods 1 and 2 was behavior-related. Among behavior-related issues, inappropriate healthcare professional behavior was predominant in both periods and mainly involved resident physicians. Ethical issue numbers regarding end-of-life (EOL) care significantly decreased in the proportion with respect to ethical issues during Period 2 (P = 0.044). In conclusion, the decreased incidence of cases with identified ethical issues in Period 2 might be associated with ethical enhancement related with EOL and improvements in the ICU care environment of the studied hospital. However, behavior-related issues involving resident physicians represent a considerable proportion of ethical issues encountered by critical care nurses. A systemic approach to solve behavior-related issues of resident physicians seems to be required to enhance an ethical environment in the studied ICU.

Keyword

Intensive Care Units; Ethics; Critical Care; Nurses; Behavior; Questionnaires

MeSH Terms

Critical Care Nursing/*ethics
Humans
*Intensive Care Units
Nurses
Retrospective Studies
Terminal Care
Tertiary Care Centers

Figure

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  Fig. 1 Personnel involved in inappropriate behavior of healthcare professional between Periods 1 and 2. Period 1, February 1, 2002- January 31, 2003; Period 2, August 1, 2011-July 31, 2012.

Reference

1. Nelson RM. Ethics in the intensive care unit. Creating an ethical environment. Crit Care Clin. 1997; 13:691–701.

2. Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a team performance framework for the intensive care unit. Crit Care Med. 2009; 37:1787–1793.

3. Sibbald RW, Lazar NM. Bench-to-bedside review: ethical challenges for those in directing roles in critical care units. Crit Care. 2005; 9:76–80.

4. Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care. 2007; 13:482–488.

5. Poncet MC, Toullic P, Papazian L, Kentish-Barnes N, Timsit JF, Pochard F, Chevret S, Schlemmer B, Azoulay E. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007; 175:698–704.

6. Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinová K, Lafabrie A, Abizanda R, Svantesson M, Rubulotta F, Ricou B, et al. ; Conflicus Study Investigators and for the Ethics Section of the European Society of Intensive Care Medicine. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med. 2009; 180:853–860.

7. Breen CM, Abernethy AP, Abbott KH, Tulsky JA. Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med. 2001; 16:283–289.

8. Studdert DM, Mello MM, Burns JP, Puopolo AL, Galper BZ, Truog RD, Brennan TA. Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Intensive Care Med. 2003; 29:1489–1497.

9. Ferrand E, Lemaire F, Regnier B, Kuteifan K, Badet M, Asfar P, Jaber S, Chagnon JL, Renault A, Robert R, et al. French RESSENTI Group. Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions. Am J Respir Crit Care Med. 2003; 167:1310–1315.

10. Festic E, Wilson ME, Gajic O, Divertie GD, Rabatin JT. Perspectives of physicians and nurses regarding end-of-life care in the intensive care unit. J Intensive Care Med. 2012; 27:45–54.

11. Agård AS, Maindal HT. Interacting with relatives in intensive care unit, Nurses' perceptions of a challenging task. Nurs Crit Care. 2009; 14:264–272.

12. Farrell ME, Joseph DH, Schwartz-Barcott D. Visiting hours in the ICU: finding the balance among patient, visitor and staff needs. Nurs Forum. 2005; 40:18–28.

13. Koh Y. Critical care medicine in Korea: problems and a solution. J Korean Med Assoc. 2010; 53:360–361.

14. Koh Y. Current status of end-of-life care in Korean hospitals. J Korean Med Assoc. 2012; 55:1171–1177.

15. Koh Y, Heo DS, Yun YH, Moon JL, Park HW, Choung JT, Jung HS, Byun BJ, Lee YS. Charactersitics and issues of guideline to withdrawal of a life-sustaining therapy. J Korean Med Assoc. 2011; 54:747–757.

16. DuVal G, Clarridge B, Gensler G, Danis M. A national survey of U.S. internists' experiences with ethical dilemmas and ethics consultation. J Gen Intern Med. 2004; 19:251–258.

17. Cobanoğlu N, Algier L. A qualitative analysis of ethical problems experienced by physicians and nurses in intensive care units in Turkey. Nurs Ethics. 2004; 11:444–458.

18. DeWolf Bosek MS. Identifying ethical issues from the perspective of the registered nurse. JONAS Healthc Law Ethics Regul. 2009; 11:91–99. quiz 100-1.

19. Danjoux Meth N, Lawless B, Hawryluck L. Conflicts in the ICU: perspectives of administrators and clinicians. Intensive Care Med. 2009; 35:2068–2077.

20. Chen YY, Chu TS, Kao YH, Tsai PR, Huang TS, Ko WJ. To evaluate the effectiveness of health care ethics consultation based on the goals of health care ethics consultation: a prospective cohort study with randomization. BMC Med Ethics. 2014; 15:1.

21. Schneiderman LJ, Gilmer T, Teetzel HD, Dugan DO, Blustein J, Cranford R, Briggs KB, Komatsu GI, Goodman-Crews P, Cohn F, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA. 2003; 290:1166–1172.

22. Fassier T, Lautrette A, Ciroldi M, Azoulay E. Care at the end of life in critically ill patients: the European perspective. Curr Opin Crit Care. 2005; 11:616–623.

23. Azoulay E, Metnitz B, Sprung CL, Timsit JF, Lemaire F, Bauer P, Schlemmer B, Moreno R, Metnitz P. SAPS 3 investigators. End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med. 2009; 35:623–630.

24. Wlody GS. Nursing management and organizational ethics in the intensive care unit. Crit Care Med. 2007; 35:S29–S35.

25. Abbott KH, Sago JG, Breen CM, Abernethy AP, Tulsky JA. Families looking back: one year after discussion of withdrawal or withholding of life-sustaining support. Crit Care Med. 2001; 29:197–201.

26. Tapper EB, Vercler CJ, Cruze D, Sexson W. Ethics consultation at a large urban public teaching hospital. Mayo Clin Proc. 2010; 85:433–438.

27. Romano ME, Wahlander SB, Lang BH, Li G, Prager KM. Mandatory ethics consultation policy. Mayo Clin Proc. 2009; 84:581–585.

28. Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, Papazian L. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007; 175:686–692.

29. Ahern SP, Doyle TK, Marquis F, Lesk C, Skrobik Y. Critically ill patients and end-of-life decision-making: the senior medical resident experience. Adv Health Sci Educ Theory Pract. 2012; 17:121–136.

30. Gorman TE, Ahern SP, Wiseman J, Skrobik Y. Residents' end-of-life decision making with adult hospitalized patients: a review of the literature. Acad Med. 2005; 80:622–633.

31. McCue JD, Sachs CL. A stress management workshop improves residents' coping skills. Arch Intern Med. 1991; 151:2273–2277.

32. Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005; 165:2595–2600.

33. Puntillo KA, McAdam JL. Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: challenges and opportunities for moving forward. Crit Care Med. 2006; 34:S332–S340.