medical futility in the ER

Medical Futility and Moral Distress in Emergency Nursing


Introduction

Medical futility is an emerging problem to Emergency Room nurses. As a result, ER nurses experience high levels of moral distress. The consequential moral distress leads to emotional and physical problems by the affected nurse, negative impact on patient care, burnout, and high turnover. Attention to the affect of moral distress and medical futility on other nursing specialties has been explored, however the specialty of emergency nursing has been neglected.

This article is aimed at examining the phenomenon of moral distress caused by medically futile practices in the ER. Focus will include the importance of recognizing this phenomenon as well as efforts to address it.

Defining Moral Distress

Andrew Jameton described nursing moral distress as the painful feelings and psychological upset that occurs when nurses face ethical dilemmas, and are unable to react in the manner they deem ethically appropriate (Corley, 2002). Institutional policies, lack of time, unsupportive supervisory staff or legal limitations may prevent the nurse from acting the way they think is necessary (Corley, 2002).

Jameton described a distinction between initial and reactive moral distress. Initial moral distress happens when nurses experience anger, frustration, and anxiety as the ethical dilemma presents itself, and the nurse cannot react to it as they believe is ethical (Corley, 2002). Reactive distress occurs after the nurse is unable to act according to their personal ethical guidelines (Corley, 2002). There is also a difference in moral dilemmas and moral distress. A moral dilemma has more than one right action, but acting on one prohibits action on the others (Corley, 2002). The action of doing the right thing is also doing something wrong, because of the inability to do the other right things. Webster and Bayliss recently broadened the definition of moral distress by stating it is the failure to engage in doing the right thing, or failure to do the right thing according to personal values because of an error in judgment, or circumstances beyond control (Corley, 2002). This moral distress can result in compromised personal values, and moral residue.

Impact of Moral Distress on Nurses

The majority of study on the moral distress that affects nurses has been done in the intensive care and acute care settings (McCarthy, 2008). The research has indicated that the majority of moral distress has come from aggressive treatments of critically ill patients, treatments that are deemed futile, unequal power balances amongst colleagues, or inadequate or incompetent coworkers (McCarthy, 2008). The research has been conducted by a series of qualitative studies with the exception of Corley, who developed the Moral Distress Scale in order to validate the research with empirical data.

Corley’s study in 2001 indicated that many nurses experience a high level of moral distress which has resulted in 15% or the nurse participants to leave positions due to the moral distress they experienced (McCarthy, 2008). Moral distress has been associated with feelings of frustration, anger and anxiety. The manifestations of moral distress includes anger, frustration, guilt, loss of self worth, depression, nightmares, suffering, anger resentment, sorrow, anxiety, helplessness, and powerlessness (Zuzelo, 2007).

Another study found that new graduate nurses experienced levels of moral distress due to disappointment, doubt, and blame once they realized they were not accomplishing the goals they had set for themselves in nursing schools (McCarthy, 2008). The methods of coping with their distress was to leave the unit they were working in search of better working conditions, cutting down on the amount of hours worked, changing their career entirely, or blaming the nursing administration or hospital system (McCarthy, 2008). A study that collaborated with the one mentioned above described the emotions that nurses felt when experiencing moral distress. The emotions ranged from emotional exhaustion, abandonment, lack of respect, or lack of belonging (McCarthy, 2008).

Moral distress is a significant problem in nursing, and can lead to a compromise in personal integrity, or a wounded moral conscience. The compromise of personal integrity results in an irreversible alteration of self. Hanna states, “moral distress involves a perceived violation for the person [that] can produce a disconnection from self and others (Hanna, 2004, p. 76). According to Webster and Baylis, the compromise of one’s integrity can lead the nurse to underestimate or deny that anything is wrong. The nurse may then “compartmentalize” the self in order to deflect the compromise experienced in the workplace is recognized as not changing the personal self (McCarthy, 2008). Consequently, Some people may lose their perspective on their own morals, and act on the basis of fear of repercussion.

Medical Futility Defined

Currently medical futility refers to interventions that are not likely to produce any significant benefit for the patient. There are two types of futility distinguished, qualitative and quantitative. Qualitative futility refers to the quality of the benefit an intervention will produce is exceedingly poor, and quantitative refers to the likelihood that an intervention will benefit the patient is exceedingly poor (Jecker, 1998). Both definitions refer to the benefit to the patient that a patient is able to appreciate.

In a widely cited article by Schneiderman et al proposed a definition of medical futility in both the quantitative and qualitative aspects, but include the belief that “ a treatment is deemed futile if empirical data demonstrates less than 1% chance of success” (Schneiderman, 1990) or if the treatment produces chronic unconsciousness or fails to end critical care support.

Since there is a wide range of definitions and no consensus amongst health care professionals to find specific meaning in futility, a legal and ethical movement must be accomplished in order to prevent undue moral distress in healthcare professionals.

Medical Futility in the Emergency Room

The emergency room requires rapid decision making in regards to treatments. The decisions are made with the expected risks and benefits to the patient, family, and society. With some treatments, the expectation of benefit is low, or considered medically futile. The decision made in regards to the benefit of treatment should be based on empirical evidence, societal and professional standards. These decisions should not be made on individual prejudice. Currently here is no ethical or legal obligation to healthcare providers to provide medical treatments they deem futile. Judgments made in the ER have special significance because of the considerable consequences of administering or withholding interventions.

Special considerations of the emergency room is that there is often a lack of information about the patient on arrival, surrogates are unavailable, or the presenting information is incorrect. Because of these circumstances, nurses are required to make decisions based on evidenced based practice, patient and family wishes, and professional judgment. In consideration of withholding interventions, the risks and benefits should be carefully weighed by the nurse. The ultimate goal of the intervention is to prolong death, and restore the patient to health, with this in mind, circumstances may arise that blur the lines of the benefit to the patient. The family members of the patient may become involved, and reassurance, guilt resolution, and the provision of additional time to accept poor prognosis may be necessary. Patient and family care should continue to be provided even if certain medical treatments are withheld. Support, guidance, and palliative care may be more beneficial to the patient and family than that of technological advances.

In the emergency room, there are four concepts of futility in regards to resuscitative efforts that were discovered by Brody and Halevy. The first is physiologic futility meaning failure to produce and physiologic response. The second is imminent demise futility, which is failure to prevent death in the near future. The third is lethal condition futility, which is failure due to underlying lethal condition that will result in death in the distant future. The fourth is qualitative futility which is failure to lead to an acceptable quality of life. As the progression of the types of futility one would experience in the emergency room, each type becomes broader in concept and toward a more controversial group of patients (Brody, 1995).

Medical Futility Causing Moral Distress

Many physicians have admitted in the past to have ordered treatments that are medically futile (Mohammed, 2009). Medical futility raises concerns for healthcare providers. The care that is ordered is often aggressive, and can be viewed as cruel and inhumane. It may not be in the best interest of the patient, and moral integrity can be questioned as a result. Because of the negative effects of futility on nurses, there is a need to address new standards of treatments, and evaluate end-of-life care.

Participating in medically futile acts causes moral distress on healthcare providers, and it has been shown that nurses are more effected by this than are physicians (Mohammed, 2009). However, institutional constraints bind nurses to act in ways that do not reflect their own personal values. Nurses are also exposed to the death and dying process around the clock, and are required to deal with invasive technologies, and their impact on the dying human body.

Medical futility is widely practiced, and will only continue to increase in frequency as the move in healthcare is toward socializing medicine. There is a great need for why these practices continue when it has been proven to cause moral distress and burden patients and families. These practices continue because of the social need for such treatments to continue when facing death and dying.

A common practice in the ER is t perform CPR. Depending on the age of the patient, the co morbidities, the chances of being successful with CPR are so low, it can be considered futile. Peberdy et al. reported that only 1-6% of hospitalized patients survive CPR, and only 17% of the survivors lived long enough to be discharged out of the hospital (Peberdy M, 2003).

Proposed Future Research

A measure of the amount of moral distress on emergency room nurses would be beneficial to the profession. As the move in politics is gaining momentum on socialized medicine, there will be fewer resources available to patients in ERs due to the increased demand for emergency care. Moral distress will become a larger problem in the future, and the nursing shortage may increase, Methods of reducing moral distress in the emergency room will help decrease nursing burnout and increase retention.

The impact of nursing moral distress on patient outcomes is essential to the improvement of healthcare in the emergency room. With recognition that end-of-life issues arise, and cause nurses to act in ways they find morally disturbing, methods can be devised so that patient care is not compromised. A study on how nurses with moral distress affects the impact on patient care in the emergency room would assist in the recognition that a reduction of moral dilemmas is essential.

The value of educating the public on realistic expectations of morbidity and mortality in relation to the emergency room can assist in decreasing the demand for care that patients, families and care givers request that may be futile. Research regarding the education provided to the general population before and after end-of-life situations will allow the recognition of where disparities exist.

Two additional aspects or research that should be addressed are the perception of medical futility in the ER from the nurses perspectives, and the impact or treatment withdrawal of medically futile treatments on the nursing staff, the patients, families and caregivers. All of this information will assist in developing methods to reduce moral distress in ER nurses. With a reduction of moral distress will come an improvement in patient care, less nursing burnout and turnover, as well as improvement in psychological equilibrium.


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