by Asma Fazal, M.B.B.S, MRCPI, MHSc
To care for children in the neonatal intensive care unit (NICU) and the pediatric intensive care unit (PICU) is not easy because in addition to having an emotionally charged environment with high morbidity and mortality, it has a patient population who is not autonomous. Caring for these children in a highly tense environment requires difficult decision-making, which can be ethically challenging at times. These ethical challenges may arise, and vary from lack of interprofessional collaboration, conflicts in values regarding what is the right thing to do in the clinical context, to inter-professional disputes between physicians and other healthcare professionals which leads to moral distress.
I have worked in many pediatric hospitals across the globe, including Pakistan, United Kingdom, Ireland and Canada, and had the opportunity to collaborate with pediatric healthcare professionals and allied healthcare staff from diverse backgrounds. In the vision and mission statement of many pediatric tertiary care hospitals, in addition to excellence, compassion, integrity, and innovation, there is a great emphasis on interprofessional collaboration, but in some cases, this collaboration is overlooked.
In NICU and PICU, conflicting perspectives of healthcare professionals are challenging for collaboration. Disproportionate care, i.e., the care which does not fulfill the criteria of being in the best interest of the patient like inadequate pain relief, doing non beneficial life sustaining treatments, continuing interventions in situations where they seem futile, inappropriate care, hastening dying process; to situations where the treatments and interventions can cause more pain and suffering, make healthcare providers think that they are unable to advocate for the child. This feeling is the leading cause of moral distress in these places.
The ethical climate of NICU and PICU plays a vital role in these interprofessional conflict situations. The lack of collegiality, poor communication, and hierarchy of power between different healthcare professionals affects how these professionals can act out their moral position. Often it happens that a person who is at a lower level in the hierarchy has to obey such orders from their superior which are against or in conflict with their own opinions and values, because they have to survive in that working environment for various reasons (employment, training etc). For example, the decisions made by an attending are of more value, and any advice from a resident or an intern is usually rejected because they are considered inexperienced even if they have updated knowledge about the treatment protocols. Nurses are particularly vulnerable in this value conflict first because of their perceived inability of decision making, and second because of the uniqueness of the nurse-patient relationship. Due to the one to one care in NICU and PICU, nurses have first hand knowledge of their patient’s condition. They are the ones who have seen the improvement and deterioration in their patient’s condition and the emotional aspect associated with these events. In these situations, when a suggestion given by the nurse regarding his/her patient which can vary from stopping invasive interventions like doing ECMO in a child whose recovery is questionable to doing daily intravenous cannulation in a child who has very poor venous access and is at end of life, can lead to mounting moral distress.
Despite all the efforts to advocate interprofessional collaboration, physicians are still portrayed as the ones who are continuing the goals of “saving life” and “furthering the advancement of science.” This impression leaves the rest of the clinical care team without recognition, which in turn leads to prioritizing the opinions of the physicians and ignoring the views and suggestions of the other healthcare staff which is not a fair thing to do while working as a team.
As staff experience moral distress at all levels, especially while working in NICU and PICU, it should not be ignored. After identification, I think coping strategies at an individual level like venting to other colleagues, self reflection and meditation are not sufficient to reduce moral distress. The reduction of moral distress is closely linked to the environment of the department and the work organization and whether it has a support system in place for constructive ethical discussion. Therefore, the focus of intervention must be on the management at the departmental and organizational level. Organizational support can prepare health care professionals to face conflicts and ethical dilemmas that may arise in their daily clinical practice.
Additionally, many healthcare professionals report a lack of educational sessions in ethics. Healthcare professionals also complain about the absence of a forum for discussing ethical issues. The ethical issues are mainly discussed in informal meetings at the departmental level like during coffee breaks and lunch breaks. A hospital’s bioethics department, being a neutral body, can be an excellent platform to discuss such issues.
Systematic education in ethics for healthcare professionals is essential. There should be a safe forum to discuss ethical dilemmas because from my experience of dealing with moral distress very well after receiving ethics education, I can suggest that letting healthcare professionals realize that ethical dilemmas can be analyzed and reasoned in different ways, can prevent and in some cases can treat moral distress. This realization can help healthcare professionals to understand the process of ethical decision-making in a better way and be prepared to deal with related situations in the future. Ethics rounds, ethics debriefings that focus on interprofessional conflicts could be the forums to discuss issues causing moral distress. Bioethics education days, workshops and interprofessional collaboration events in which different professionals meet with each other informally can also be other platforms to initiate a conversation.
Interprofessional collaboration improves clinical effectiveness and job satisfaction which plays an important role in the reasonable and ethically justifiable care for the child. At my hospital, interprofessional collaboration is considered an important component of patient care. Seeing this practice successfully working, I hope that these interventions will help the healthcare professionals in other hospitals identify ethical dilemmas in the early stage and will increase the acceptance and respect for others moral perspective. These initiatives will help in reducing moral distress of the healthcare staff leading to improve patient care, hence fulfilling the principle of best interest.